Medical Prior Authorization Requirements / Medical Procedures Guidelines
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Governs AvMed's prior authorization requirements, delegates, and processes for medical procedures and services for all AvMed members and product lines; affects providers (in-network and out-of-network), delegated vendors, and members in North Carolina and nationally where specified.
No material clinical or coverage changes in this revision.
Authorization and Coverage Criteria
inv-01: Authorization and coverage criteria (partial)
Services that require prior authorization, items considered investigational/non-covered, and outpatient rehabilitative therapy notes.
ALL of the following
ALL of the following
- All inpatient admissions and observation for surgical and non-surgical stays require authorization notification; emergency room services without an overnight stay do not require authorization.
ALL of the following
- Maternity and newborn confinements require authorization; inpatient SNF, LTACH and acute rehabilitation facilities require prior authorization.
ALL of the following
- Behavioral Health and Substance Abuse services (inpatient and outpatient hospital services, including Partial Hospitalization and Intensive Outpatient Programs) require authorization by Optum Behavioral Health.
ALL of the following
- Authorizations for diagnostic and complex imaging are managed by the delegated vendor (EviCore).
ALL of the following
- Home health and certain durable medical equipment items require prior authorization and are processed by delegated vendors; contact IHCS for DME management per regional instructions.
ALL of the following
- Authorization is not required when services are provided by an in-network provider; habilitative therapy is covered when intended to maintain, develop, or improve skills and functions necessary for daily living.
Investigational / Non‑covered examples
- Any item or service that may be considered investigational or experimental must be reviewed and decisioned in advance and may not be covered.
- Examples include but are not limited to: Magnetoencephalography (MEG); Platelet Rich Plasma (PRP); Percutaneous Tibial Nerve Stimulation (PTNS); MLS Laser Therapy; Thermal Capsulorrhaphy; Chronic Intermittent Intravenous Insulin Therapy (CIIT); Breast Thermography; Ligament Augmentation LARS; cosmetic services; custodial care.
ALL of the following
- Prior authorization is required after a maximum of five visits to dermatologists in a 12‑month period for a dermatologic problem; consult the PAL for code‑level guidance.
ALL of the following
- Providers should verify member plan benefits and limits prior to rendering care; services and delegated vendor responsibilities may vary by product and geography.
- Providers must submit authorization requests via Availity Provider Portal or delegate-specified channels (or fax where allowed); follow delegated vendor instructions for specialty services.
inv-02: Authorization and Coverage Criteria
Coverage and authorization rules; verify the member's plan for specific limits, delegated processes, and exceptions.
ALL of the following
- Verify benefits and authorization requirements prior to rendering care; authorization requirements and covered services may change over time.
Outpatient rehabilitative / habilitative therapy
- Authorization is not required when rehabilitative services (physical, occupational, speech, habilitative) are provided by an in‑network provider.
- Rehabilitative therapies provided to improve or restore physical functioning following disease, injury or loss of a body part do not require prior authorization but are subject to member plan benefit limits.
- Certain PT modalities are considered investigational and currently unavailable (examples include Interactive Metronome, Kinesio Taping, Augmented Soft Tissue Mobilization, MEDEK Therapy, Hands‑Free Ultrasound/Infrasound); check plan coverage.
ALL of the following
- Authorization is required for outpatient pain management services generally; in‑network pain management specialists providing office‑based services may not require prior authorization; surgical pain management may require prior authorization.
ALL of the following
- Prior authorization is required for many DME, prosthetic and orthotic devices and certain supplies; prosthetic coverage is limited to devices that restore bodily function (e.g., artificial limbs, joints, ocular prostheses, cochlear implants).
- Contact Integrated Home Care Services (IHCS) for DME management and verify applicable PAL codes and plan limits.
ALL of the following
- All surgical procedures in hospital or ambulatory surgery centers require prior authorization unless the procedure and code are listed on the Prior Authorization List (PAL) as not requiring authorization; submit codes not on the PAL for review.
Specialty services requiring authorization
- Neurostimulator trials and implants require prior authorization and are subject to benefit limitations.
- Hyperbaric oxygen therapy requires prior authorization and is subject to benefit limitations.
- Wound vacuums/negative pressure therapy require prior authorization.
- Other specialty services (transplants, radiation oncology, cardiac procedures, dialysis, neuropsychological testing for medical diagnoses) require prior authorization and may be managed by delegated vendors; effective dates or management changes (for example, radiation oncology management change effective 01/01/2026) should be observed.
ALL of the following
- Authorization is mandatory for out‑of‑network services except emergency care; exceptions may exist for certain POS/Choice second‑opinion benefits; verify coverage before service.
Code References and Coding Rules
| Prior Authorization List of Codes (PAL) https://pal.avmed.com/ |
| List of codes AvMed Radiology and Cardiology Code List (see https://www.evicore.com/sites/default/files/resources/2024-01/AvMed_Radiology_CodeList_Eff01.01.2024_Pub01.30.2024.pdf) |
| see PAL | Prior Authorization List of Codes maintained online at https://pal.avmed.com/ |
Provider Submission, Delegation, and Authorization Processes
Submit authorizations via Availity; observe standard and urgent turnaround times
Authorization requests must be submitted electronically via the Availity Provider Portal for Authorizations and Referrals, or by completing a Medical Prior Authorization Request form and faxing it to AvMed. Requests are processed by urgency: standard (decision within 15 calendar days for commercial plans), urgent/expedited (decision within 72 hours), and urgent concurrent (decision within 24 hours).
- Submit via Availity Authorization and Referral Provider Portal (preferred).
- Or complete the Medical Prior Auth Request Form and fax to 1-800-552-8633.
- Turnaround: Standard = 15 days; Urgent/Expedited = 72 hours; Urgent Concurrent = 24 hours.
Use Availity Provider Portal (preferred); fax as alternative
Preferred submission is through the Availity Provider Portal for Authorizations and Referrals; providers may also fax completed Medical Prior Authorization request forms to AvMed's prior authorization department at 1-800-552-8633.
- Availity portal: www.availity.com or Provider Implementation Hub | AvMed.
- Fax option: 1-800-552-8633 using the Medical Prior Auth Request Form.
Authorize all inpatient admissions and observation stays (ER without overnight stay excluded)
All inpatient admissions and observation stays (surgical and non‑surgical) require authorization notification; emergency room services without an overnight stay do not require authorization.
- Maternity, newborn confinements, SNF, LTACH and acute rehabilitation also require authorization.
- Hospital use only: emergent, urgent direct admissions procedures noted in policy.
Obtain authorization for Out‑of‑Network services (emergencies excluded)
Authorization is mandatory for all out‑of‑network services except emergency care; providers should verify member coverage and any POS/Choice benefit exceptions prior to rendering services.
- Second medical opinions from OON providers may not require auth for members with POS or Choice benefits—verify on www.avmed.org or via Provider Service Center.
- Contact Provider Service Center at 800‑452‑8633 to confirm coverage before service.
Behavioral health authorizations handled by Optum Behavioral Health
Behavioral Health and Substance Abuse authorizations (inpatient and outpatient, including Partial Hospitalization and Intensive Outpatient Programs) are managed by Optum Behavioral Health; providers may request authorization via AvMed's Behavioral Health Service Center powered by Optum.
- AvMed Commercial Behavioral Health phone: 866‑293‑2689.
- Optum/ProviderExpress options available for participating providers.
Radiology authorizations are managed by EviCore
Radiology authorizations for all AvMed members (diagnostic, complex radiology, nuclear and cardiac imaging) are managed by EviCore; providers must submit requests to EviCore per its processes.
- EviCore website and resources: http://www.evicore.com/ and AvMed-specific EviCore resources.
- EviCore contact: 800‑792‑8790; fax 800‑540‑2406.
Delegated vendors process home health, DME, and certain supplies
Home health, Durable Medical Equipment, and certain home infusion/ostomy/urology/wound supplies are processed by delegated vendors (e.g., Integrated Home Care Services, BayCare Home Care, Advanced Care Solutions, PNS); providers must contact the appropriate delegate for authorizations.
- Integrated Home Care Services (IHCS) for Florida counties: Call 844‑215‑4264, Fax 844‑215‑4265.
- BayCare Home Care for specified counties (home infusion): 800‑940‑5151.
- PNS (Podiatry Network Services): 844‑222‑3939; Advanced Care Solutions contact for previously serviced members.
Radiation oncology authorizations managed by AvMed beginning 01/01/2026
Effective 01/01/2026, commercial radiation oncology authorizations will be managed directly by AvMed; submit Radiation Therapy requests via the Availity Authorization and Referral Provider Portal or fax the Medical Prior Auth Request Form to 1‑800‑552‑8633.
- Submit via Availity Provider Portal or fax form as instructed.
- Change effective date: 01/01/2026 indicates AvMed responsibility for commercial radiation oncology authorizations.
Verify and obtain authorization for Out‑of‑Network services before care
Authorization is mandatory for all out‑of‑network services except emergency care; verify member coverage prior to rendering services via AvMed's website or the Provider Service Center.
- Verify coverage at www.avmed.org or call Provider Service Center at 800‑452‑8633.
- Note exceptions for POS/Choice benefits for second opinions—confirm on a case-by-case basis.
Outpatient pain management generally requires authorization; in‑network office PM exceptions apply
Authorization is required for all outpatient pain management services (including surgical pain management at ASCs or hospitals); however, pain management services provided by an in‑network PM specialist in an office setting do not require prior authorization.
- Surgical pain management services provided in an office setting may require prior authorization—check PAL for codes.
- Refer to Prior Authorization List of Codes (PAL) at https://pal.avmed.com/ for specific code requirements.
Prior authorization required for hospital/ASC surgical procedures unless PAL exempts them
All surgical procedures performed in a hospital or ambulatory surgery center require prior authorization unless specifically listed on the Prior Authorization List (PAL) as not requiring authorization; if a code is not on the PAL, submit it for review.
- Use the PAL (https://pal.avmed.com/) to verify whether authorization is required for specific procedure codes.
- Submit surgical codes not listed on the PAL to AvMed for review and determination.
Prior authorization required for DME, prosthetics, orthotics, wound vacuums and certain supplies
Durable Medical Equipment, prosthetic and orthotic devices, wound vacuums/negative pressure therapy, and certain related supplies require prior authorization; contact Integrated Home Care Services (IHCS) or verify PAL codes and requirements.
- IHCS contact: Call 844‑215‑4264, Fax 844‑215‑4265.
- Verify device coverage and PAL code requirements online at https://pal.avmed.com/.
Obtain prior authorization for neurostimulators, wound vacuums, hyperbaric oxygen
Specialty procedures such as neurostimulator trials/implants, wound vacuum/negative pressure therapy, and hyperbaric oxygen therapy require prior authorization and may be subject to benefit limitations and management.
- Neurostimulator trial and implantation require authorization; verify benefit limitations.
- Wound vacuum systems and hyperbaric oxygen therapy require prior authorization and may have specific vendor/contracted provider requirements.
Verify benefits and authorization requirements prior to providing services
Providers must verify member benefits and whether prior authorization is required before rendering care and should contact the Provider Service Center to confirm requirements or changes.
- Provider Service Center phone: 800‑452‑8633.
- Check the Prior Authorization List of Codes (PAL) at https://pal.avmed.com/ for current requirements.
Key Definitions
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