Prior Authorizations
Commercial Health Plans
The following services require prior authorization from Network Health Plan/Network Health Insurance Corporation:
- All services to be provided by a non-participating practitioner or facility
- All transplant services, including evaluations and work-ups
- All hospital inpatient services including skilled nursing facilities, rehabilitation services facilities and behavioral health facilities
- All services considered experimental, investigational, or research, including all CPT Category III codes (Experimental, Investigational services list available for reference; go to our Care Management Policies page for more information)
- Services (procedures and surgeries) at participating ThedaCare facilities involving anesthesia rendered 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, Prophylactic Mastectomy
- Keratoplasty
- Port Wine Stain removal
- Rhinoplasty, rhytidectomy
- Uvulopalatopharyngoplasty (UPPP) and SRUP, RAUP, LAUP
- Sclerotherapy
- Blepharoplasty, canthoplexy, canthoplasty
- Panniculectomy
- Otoplasty
- Pectus excavatum repair
- All procedures that could be considered cosmetic
- The following select services:
- Acupuncture
- DME and orthotics over $750.00 (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 (Kimberly Clark employer group has $300.00 dollar requirement: DME Grid available for reference)
- Repairs and Replacement of DME over $500.00 (Kimberly Clark employer group has $300.00 dollar requirement)
- Prosthetics over $1000.00 (based on Medicare Fee Schedule purchase price, if not on Schedule then purchase price; DME Grid available for reference)
- Home Health Care & Hospice Services
- Home IV Therapy
- Genetic Testing Services
- PT/OT/ST upon initial visit for treatment (evaluation allowed without authorization)
- Facility-to-facility and/or non-emergent ambulance transfers
- Dental Care for Accidents
- 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 upon initial visit for treatment (evaluation allowed without authorization)
- Substance Abuse Treatment
- Mental Health and Substance Abuse Transitional Care including: Partial Hospitalization, Day Treatment, and Intensive Outpatient Services and Substance Abuse Residential Care
- Obstetrical Care (This is notification only and is used for Case Management purposes)
Please note:
- CT, MRI, MRA, PET and Nuclear Cardiology scans are prior authorized through National Imaging Associates.
- Refer to the commercial Preferred Drug List for authorization requirements regarding injectable medications given in an ambulatory or outpatient setting.
*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.
Obtain a Prior Authorization
Please contact our Care Management Department or our Behavioral Health Services department to request a prior authorization. Click here for our contact information.