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Preauthorization Requirements, Policies

Preauthorization

Preauthorization 

Providers: Download the Preauthorization/Prior-Auth Request Form

To help contain costs and ensure that the services paid for by your health plan are medically necessary and appropriate, some services require our authorization before you receive them. Failure to receive our preauthorization for the services listed below could result in coverage for the service being denied. If we do cover a service for which preauthorization was required but not obtained, the member or provider could be responsible for a penalty of 50% of the cost of the service, up to $500. 

Hospital Admission Notification

All our health plans require you notify us before you have an inpatient stay for medical and behavioral health care.

Planned Hospital Admissions

If you or anyone in your family is expected to stay overnight in a hospital, call us at 800.279.4000 before you're admitted.
You will want to call at least five days in advance whenever possible to keep everything running smoothly. Since this notification is a plan requirement, your reimbursement for services may be reduced unless you notify us.  Please check your policy for specific notification requirements for maternity-related admissions and emergencies.

Emergency Hospital Admissions

If you are admitted to the hospital for an emergency, notify us within 72 hours following the emergency.

Services Requiring Preauthorization

  • Advanced imaging scans (e.g. MRI, CT scans) of the neck and spine provided on an outpatient basis. Such scans provided while you are inpatient or provided as part of emergency care are not subject to preauthorization. * 
  • Autologous Chondrocye Implantations (Effective 9/1/16)
  • Behavioral Health Care:
    • Partial hospitalization
    • Intensive outpatient
    • Residential services
  • PET Scans 
  • MRA Scans 
  • Back surgeries for pain
  • Continuous glucose monitors and supplies 
  • Dialysis (outpatient and home dialysis) 
  • Invasive Back Procedures 
  • Certain high-cost durable medical equipment, prosthetics, orthotics and oxygen-related equipment and services 
    • CPAP, BiPAP, and VPAP machines
    • Apnea monitors and oral appliances for the treatment of apnea
    • Ventilators and supplies
    • Oxygen concentrators
    • Stimulators – bone, brain
    • Home infusion
    • Enteral Nutrition
    • Home infusion/ambulatory infusion pumps
    • Specialty beds and accessories
    • Defibrillator vest
    • Power wheelchairs and accessories
    • Power operated vehicles (i.e. scooters)
    • Artificial limbs
    • Custom back braces
    • Lower extremity braces
    • Chest Compression System 
  • Cochlear Implants (Effective 9/1/16)
  • Elective and/or planned inpatient stays prior to admission 
  • Electroconvulsive Therapy 
  • Gastric Neurostimulators (Effective 9/1/16)
  • Genetic testing
  • Home Health Services – Including Wound Care 
  • Hyperbaric Oxygen Therapy 
  • Impression and Customer Preparation; Speech Aid Prosthesis
  • Insulin Pumps and Supplies 
  • Nuclear Medicine – Cardiology (Myocardial Perfusion Imaging, Tomographic/Planar) 
  • Orthognathic Procedures   **these are still not covered for WEA Trust members in the State Health plan.
  • Osteochondral Autograft Knee, Open (Effective 9/1/16)
  • Physical, speech, and occupational therapy services (excluding evaluations)
  • Psychological and neuropsychological testing [Use this form when requesting authorization]
  • Reconstructive or plastic surgery such as, but not limited to,
    • Abdominoplasty
    • Blepharoplasty and ptosis repair
    • Brachioplasty
    • Breast augmentation, lift, or other breast reconstructive surgery
    • Panniculectomy
    • Thighplasty
    • Treatment of varicose veins
  • Skilled nursing facility care 
  • Skilled rehabilitation services
  • Sleep Studies
  • Surgical Sleep Disorder Treatment 
  • Specialty drugs and high-cost drugs with unique monitoring or delivery needs
  • Tens Unit (Effective 9/1/16)
  • Total Joint Replacement  
  • Transmagnetic Stimulation
  • Transplant evaluations, services and procedures 
  • Treatment of temporomandibular disorders (TMD)
  • Whole Body Imaging (Effective 9/1/16)

* All advanced imaging scans require preauthorization for State Health Plan members.

Customer Service

800-279-4000

Our professional and courteous customer service staff is ready to answer your call, Monday through Friday - 7:30 a.m. to 5:00 p.m.

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