Services Requiring Prior Authorization

For Providers

Services Requiring Prior Authorization

  • Chemotherapy
  • Consults-Outpatient:
    1. All out of Subnetwork
    2. All out of CCP network referrals
    3. Specialist to specialist referrals
  • Dental Services specific to Orthodontics, Dentures and Appliances (MHS & NBHD only)
  • Dialysis (peritoneal & hemodialysis)
  • Elective Surgery (Inpatient, Outpatient & Ambulatory Surgery)
  • Emergency Visits (authorization is for payment only, not service approval)
  • Enteric Feedings/Nutritional Supplements
  • All Invasive Diagnostic procedures to include but not be limited to endoscopies, cardiac catheterizations, electrophysiologic studies (EPS), angiograms, cystograms, and amniocentesis
  • Growth Hormone Treatment
  • Home Health Care/DME/Oxygen & Related Equipment and Services
  • Hyperbaric Oxygen Therapy
  • Inpatient Admissions (Emergency and Non-Emergency)
  • Mental Health Inpatient Admissions (Concordia: 800-294-8642)
  • MRI
  • Observational Stays
  • Obstetrical Care (Block Authorization)
  • Oral Surgery
  • Orthotics/Prosthetics
  • PET Scans
  • Pharmacologic/Exercise/Echo Stress Tests (Thallium, Cardiolyte, etc.)
  • Plastic Surgery
  • Radiation Therapy
  • Sleep Apnea Studies and Related Care
  • Therapy Services – Speech/Occupational/Physical Therapies
  • Transplants and Related Care
  • Any service authorizations/pending cases prescribed or authorized before the enrollee’s effective date with the PSN

* InterQual and national guidelines criteria and Medicaid Coverage and Limitations Handbooks will be used to evaluate requests for medical appropriateness/necessity.