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
AUTHORIZATION REQUIREMENTS
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
- MRI/MRA
- PET/SPECT
- Nuclear Medicine Studies
Allergy Testing
Except when perfored by an Allergist or Pulmonologist
Behavioral Health
Contact Beacon Health at (888) 710-2313
Chemotherapy
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
Home Health Services & Home Infusion
Contact Coastal Care Services (855) 481-0505
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.
Molecular Diagnostic Testing
Non-participating providers
Except:
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)
Private Duty Nursing
Contact Coastal Care Services (855) 481-0505
Prosthetic/Orthotics, including Cranial Orthotics
Radiation Therapy and Radiosurgery
Specialty Pharmacy Drugs
Refer to Miami Children’s Specialty Pharmacy Drug (Injectable) Prior-Authorization Requirements List
Transportation
- 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
REFERRAL REQUIREMENTS
Specialist Visits (Referral only)
Referral from PCP required except for the following:
- OB/GYN
- Chiropractor
- Dermatologist
- Podiatrist