Providers for CMS T21
To Request Authorizations, please fax to: (844) 806-0397.
For Behavioral Health Authorizations, please fax to: (800) 294-8642.

Prior Authorization Guidelines

Prior Authorization requests require the submission of supporting clinical documentation for medical review. Failure to provide clinical documentation may result in a delay / denial of the request.

Applied Behavioral Analysis (Therapy) Inpatient Admissions (Including Mental Health and Skilled Nursing Facilities) In and Out of Network
DME (Including Insulin Pumps, Wheelchairs and Scooters) Elective Surgical Procedures (Including Cosmetic and Plastic / Reconstructive Procedures)
Outpatient Surgery PPEC (signed Plan of Care Required)
MRI’s, CT Scans, PET Scans MRI’s, CT Scans, PET Scans (PT, OT, Speech and Respiratory (signed Plan of Care required)
Behavioral / Mental Health Transplants and Related Care (Professional Services rendered in the office for participating providers would not require prior Authorization)
Hearing Services / Hearing Aids Nutritional Supplements / Enteral & Parental Nutrition
Vision Services (Contact Lenses Specialty (non-standard) Glasses) Orthodontia
Orthotics & Prosthetics Out Network / Out of State Services
Home Health Care Services (Including Home Health Aids, Nursing Visits, Private Duty Nurses and Infusion Services) Experimental / Investigational Treatment** Those newly developed procedures undergoing systematic investigation to establish their role in treatment or procedures that are not yet scientifically established to provide beneficial results for the condition for which they are being used.

Emergency Room Visit – Notification Only

Observation Stays – Notification Only

*Needed for all exceeded Medicaid Limits

**Notification required for services that were rendered for coordination of care purposes only