Prior Authorization List for MMCP / MCHP

FOR MMCP: All Out-of-Network services and all services indicated below require authorization

FOR MCHP: Only the services indicated below require authorization

For an Authorization Request Form, click here

Admission Inpatient
Elective Surgical Inpatient Admission Elective Medical Inpatient Admission
Non-elective (Emergency) Admission Inpatient Rehabilitation Admission
Skilled Nursing Facility Admission
Admission Observation
Hospital Observation Services ( for any reason ) Admission / Discharge Same Day
Home Health
Skilled Nursing Visits Home Respiratory Therapy Visits
Home Social Worker Visits Home Health Aide Visits
Physician Home Visits Private Duty Nursing
Personal Care Services
Hospice
Hospice Outpatient At Home / ALF / SNF Hospice Inpatient
Diagnostic and Lab Testing
Cardiac Event Monitoring CT Scan
Cta and Calcium Scoring Genetic Testing
Growth Evaluation & Tx For Hormone Therapy MRI
MRA PET Scan
Sleep Study
Durable Medical Equipment( medical and surgical supplies do not require authorization)
Bone Growth Stimulator Clinitron and Electric Beds
CPAP and BIPAP Machines Diabetic Shoes
Custom Wheelchairs Electric Wheelchairs / Scooters
Wheelchair Accessories Insulin Pumps and Supplies
Enteral Nutrition Patient Lifts
Wound Vac Pumps
Maternity
Obstetrical Care— All Sonograms, Pre-natal Procedures and Delivery
Nutritional Services
Nutritional Consulting Nutritional Supplements / Nutrition Formulas / Enteral Nutrition
Orthotics And Prosthetics
Custom Orthotics Limb and Torso Prosthetics
Prosthetic Custom Eye, Surfacing & Fitting
Transportation
Non-emergent Ambulance Services Air Ambulance
Invasive Procedures
Capsule Endoscopy Cesarean Delivery
Chemodenerve Eccrine Glands Circumcision (Auth Required If Age > 1 Year)
Denervation Epidural Injection for Lysis
Epidural Injection for Pain Hormone Pellet Implant
Hyperbaric Treatment ( Wound Care Center only ) Oral Arthroscopy
Oral Splint Oral Surgery
Spider Vein Therapy Spider Vein Therapy - Injection / Laser
Total Disc Arthroplasty (Artificial Disc) Virtual CT Colonoscopy
Cosmetic / Plastic / Reconstructive Procedures
Adjacent Tissue Transfer / Rearrangement / Repair Bariatric Surgery
Canthoplasty Correction of Lid Retraction
Dermatological Procedures Eyelid, Excision and Repair
Foot and Toes Reconstruction Gastric Restrictive
Gastric Restrictive, Port Component Hand and Fingers Reconstruction
Head ( skull, face, TMJ ) Reconstruction Humerus and Elbow Reconstruction
Keratoprosthesis Knee, Arthroplasty, Total
Lip, Repair Mastectomy Proc / Repair, Reconstruction
Mastoid Surgery Revision Neck and Thorax Reconstruction
Nose, Repair Ocular Adnexa, Strabismus Surgery
Palatoplasty for Cleft Palate Pelvis and Hip Reconstruction
Penile Repair Skin Flaps and Grafts
Testicular Prosthesis Insertion
Transplant
Amniotic Membrane Bone- Autograft for Spine Surgery
Bone Marrow Cornea
Eye Heart
Heart-Lung Intestine
Kidney Liver
Lung Ovarian
Pancreas Pancreatic Islet Cells
Peripheral Stem Cells Skin
Tissue