Authorization and Notification Requirements
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Defines prior authorization and notification requirements for inpatient and outpatient services for Aspirus Health Plan providers, including codes, timing, forms, and contact information.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Standards
Medical Necessity Criteria Source
Services covered when medical necessity is met per referenced criteria sources
Examples: InterQual LOC Rehabilitation; InterQual Medicare Procedures; InterQual Medicare Durable Medical Equipment; InterQual Molecular Diagnostics; Medicare NCD/LCD will be chosen based on requested service
Authorization is not required for breast reconstruction associated with breast cancer. This is listed under the policy's authorization exceptions for cosmetic/reconstructive surgeries; providers do not need to request prior authorization for those breast reconstruction procedures when they are associated with breast cancer.
Codes and Code Groups Requiring Authorization
| E0483 | High Frequency Chest Wall Oscillation System |
| E0652 | Pneumatic Compression Device |
| E0748 | Osteogenesis stimulator, electrical, non-invasive, spinal applications |
| E0749 | Osteogenesis stimulator, electrical, surgically implanted |
| E0764 | Functional Neuromuscular Stimulator (rental only item) |
| E0766 | Electrical Stimulation Device |
Prior Authorization, Notification, and Documentation Requirements
Failure to obtain authorization
Failure to obtain prior authorization for services that require it may result in a denied claim. Providers are responsible for verifying member eligibility and benefit coverage prior to rendering services and obtaining any required prior authorization or network exception in advance.
- Allow up to 14 calendar days for non-urgent authorization decisions.
- All services are subject to member eligibility and benefit coverage.
- If you are not able to obtain services in your network, you may submit a network exception request prior to services.
- Providers may request a copy of the criteria used to make a medical necessity determination on Aspirus Health Plan's Authorization page.
Submission and discharge documentation
Submit the appropriate prior authorization or notification request form with supporting clinical documentation by fax or e‑mail per instructions on the form. For inpatient notifications, notify within 24 hours of admission where required and send a discharge summary within 72 hours of discharge. Concurrent review may be required for additional inpatient days.
- Notification for acute inpatient, mental health, and substance use disorder admissions: within 24 hours of admission; fax acute inpatient medical admissions to 715.787.7316; fax inpatient mental health and substance use disorder admissions to 715.787.7314.
- Discharge summary required within 72 hours of discharge.
- Aspirus Health Plan requires concurrent review for additional inpatient rehabilitation days.
Drug prior authorization and formulary note
Certain medical injectable drugs require prior authorization per the Medical Drug Policy library. Drugs covered under the pharmacy benefit are listed on the formulary available on the Formulary page. Refer to the Medical Drug Policy and formulary for prior authorization requirements and coverage details before ordering or administering medical injectable drugs.
- Medical Drug Policy library lists injectable drugs requiring prior authorization.
- Formulary indicates drugs covered under the pharmacy benefit and is available on the Formulary page.
Approval Authority and Notification Labels
Background and References
This policy uses established external medical-necessity sources to determine coverage. Medical necessity determinations for procedures, durable medical equipment, and diagnostics will follow InterQual criteria (appropriate InterQual subset selected for the requested service) and applicable Medicare National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs). Providers should supply documentation that aligns with those referenced criteria when submitting authorization requests.
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