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Prior Authorization/Referral Requirements

Effective: 12/1/18

Prior Authorization Guide

Prior Authorization Guide (Specialty Drugs)

All Non-Par Provider Requests Requires Authorization Regardless of Service


The services listed below require Prior Authorization except where noted otherwise:


All Inpatient Admissions
Notification required within 24 hours of admission or next business day
Clinical updates required with continued stay
Advanced Imaging
Except when performed in conjunction with an emergency service or an approved inpatient/observation admission:
  • CT/CTA
  • Nuclear Medicine Studies
Allergy Testing
Except when perfored by an Allergist or Pulmonologist
Behavioral Health
Contact Beacon Health at (888) 710-2313
Refer to Miami Children’s Specialty Pharmacy Drug (Injectable) Prior-Authorization Requirements List
Cosmetic and Reconstructive Procedures
Durable Medical Equipment 
Contact Coastal Care Services (855) 481-0505
Experimental or Investigational Procedures and Treatments 
Hearing Aids
Home Health Services & Home Infusion 
Contact Coastal Care Services (855) 481-0505
Hospice Care
Hyperbaric Oxygen Therapy 
Intensive Cardiac and Pulmonary Rehabilitation Services
Lab Services 
Except those services performed by Quest Laboratories and those allowed in a participating physician’s office. Please see MCHP In-Office Laboratory Test Guidelines.
Massage Therapy
Molecular Diagnostic Testing
  • DNA
  • Genetic Testing
Non-participating providers
Emergency Department
Professional fees associated with ER visit and approved outpatient or inpatient stays
OB services
  • OB ultrasound beyond 2 per pregnancy
  • Induction of labor prior to 39 weeks
  • Scheduled C-sections, regardless of gestational age
  • Non-Emergent Termination of pregnancy
Observation Stays
Beyond 24 hours
Outpatient Surgical Procedures
Except when performed in the office or ambulatory surgical center (ASC)
Pain Management
Post Discharge Meals
Private Duty Nursing
Contact Coastal Care Services (855) 481-0505
Prosthetic/Orthotics, including Cranial Orthotics 
Radiation Therapy and Radiosurgery
Sleep Studies
Specialty Pharmacy Drugs
Refer to Miami Children’s Specialty Pharmacy Drug (Injectable) Prior-Authorization Requirements List
  • Non-emergent air transportation
  • Non-emergency ambulance
Therapy (Physical/Occupational/Speech)
  • Prior authorization after initial evaluation
Vaccines - Adult Shingles Vaccine
  • Except for enrollees ages 50 and older
Vision related procedures
Contact iCare at (855)373-7627

Services that require prior authorization will not be reimbursed with a referral



Specialist Visits (Referral only) 
Referral from PCP required except for the following:
  • OB/GYN
  • Chiropractor
  • Dermatologist
  • Podiatrist
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Miami Children's Health Plan is a Managed Care Plan with a Florida Medicaid Contract. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the Managed Care Plan. Limitations, copayments, and/or restrictions may apply. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change.

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