Prior Authorizations

Commercial Health Plans, Effective 1/1/2011

The following services 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 services 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.
• All services (procedures and surgeries) at participating Bellin facilities including Bellin Memorial Hospital, Oconto Hospital & Medical Center, and Bellin Orthopedic Surgery Center that involve anesthesia services by non-participating practitioners.
• The following outpatient surgical procedures:
  • Implantable cardioverter-defibrillator insertion
  • Implantable spinal neurostimulator insertion
  • Implantable pain pump insertion
  • 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
  • Any procedure that could be considered cosmetic
• The following other services:
  • Total cervical disc arthroplasty, revision including replacement of total cervical disc arthroplasty, and removal of total cervical disc arthroplasty
  • Acupuncture
  • Durable medical equipment (DME) and orthotics over $750 (based on Medicare Fee Schedule purchase price, if not on Schedule, then purchase price) and: Scooters, insulin pumps, continuous glucose monitoring devices, electric breast pumps
  • DME repairs and replacement  over $500
  • Prosthetics over $1,000 (based on Medicare Fee Schedule purchase price, if not on Schedule then 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 treatments; initial evaluation allowed without authorization
  • 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
  • Psychological and neuropsychological testing
  • 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.

*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.