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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

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 
 
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
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)
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
Transplants
 
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