Prior Authorizations

Commercial and Self Funded Members, Effective 1/1/2012

The following services for our Commercial and Self Funded members require prior authorization from Network Health:

• Services that will be provided by a non-participating practitioner or facility
• Transplant services, including evaluations and work-ups
• Hospital inpatient services including skilled nursing facilities, rehabilitation facilities and behavioral health facilities
• Services considered experimental, investigational, or research-based, including all CPT Category III codes. For more information, please refer to Network Health's list of codes and services requiring experimental review.
• The following outpatient surgical procedures:
  • Implantable cardioverter-defibrillator insertion or replacement
  • Implantable spinal neurostimulator insertion, revision or removal
  • Implantable pain pump insertion or replacement
  • Cochlear implants
  • Breast reduction, breast implant removal or replacement, and prophylactic mastectomy
  • Keratoplasty
  • Port wine stain removal
  • Rhinoplasty, rhytidectomy
  • Uvulopalatopharyngoplasty (UPPP) and SRUP, RAUP, LAUP, RFTVR
  • Sclerotherapy
  • Blepharoplasty, canthoplexy, canthoplasty
  • Panniculectomy
  • Otoplasty
  • Pectus excavatum repair
  • All procedures that could be considered cosmetic
• The following other select services:
  • Total cervical disc arthroplasty, revision including replacement of total cervical disc arthroplasty, and removal of total cervical disc arthroplasty
  • Total lumbar disc arthroplasty, revision including replacement of total lumbar disc arthroplasty, and removal of total lumbar disc arthroplasty
  • Acupuncture
  • Durable medical equipment (DME) and orthotics over $750 (based on Medicare Fee Schedule purchase price, if not on Schedule, then retail purchase price) and: Scooters, insulin pumps, continuous glucose monitoring devices, electric breast pumps. For more information, please refer to Network Health's DME Services List.
  • DME repairs and replacement over $500
  • Prosthetics over $1,000 (based on Medicare Fee Schedule purchase price, if not on Schedule then retail purchase price). For more information, please refer to Network Health's DME Services List.
  • Home health care and hospice services
  • Home IV therapy
  • Genetic testing services, excluding Factor V Leiden and Prothrombin Gene Mutation
  • PT/OT/ST upon initial visit for treatment; initial evaluation allowed without authorization (no authorization required for PT/OT/ST services for Affinity Health System self funded members)
  • Facility-to-facility and non-emergency ambulance transfers
  • Dental care services required as a result of an accident
  • Hospital or ambulatory surgery center charges in conjunction with dental care
  • TMD surgical services
  • All non-emergency ambulatory CT, MRI, MRA, PET, Nuclear Cardiology scans*
  • Autism treatment
  • Psychotherapy visits; initial evaluation allowed without authorization
  • Substance abuse treatment
  • Mental health and substance abuse transitional care, including partial hospitalization, day treatment, intensive outpatient services and substance abuse residential care
  • Obstetrical care (for case management staff notification purposes only)

Please note:

1. CT, MRI, MRA, PET and nuclear cardiology scans are prior-authorized through National Imaging Associates.
2. Please refer to the commercial Preferred Drug List for authorization requirements regarding injectable medications given in an ambulatory or outpatient setting.
3. When requesting authorization, please provide the CPT, HCPCS, and/or Revenue Code appropriate for the planned service.

*Whether Network Health is the primary, secondary or tertiary insurer, authorization procedures must be followed to receive coverage.

*All services must be medically necessary; when a claim is submitted it will be reviewed retrospectively to determine benefit availability, certificate of coverage provisions, and claim payment agreements.