CurrentBaylor Scott & White Health PlanPolicy N/A

Notification and Prior Authorization requirements

Governs Baylor Scott & White Health Plan requirements for notification and prior authorization across product lines and services; affects providers (contracted and non-contracted) and members covered under BSWH plans.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyNotification and Prior Authorization requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2023

Next Review DateN/A

Key ActionPrior Authorization is required for ALL SERVICES provided by non-contracted providers unless using out-of-network benefits in PPO/POS products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2023-04-01policy effective date

Appliesnon-contracted provider PA

>40drug categories on PA list

Biannualupdate frequency

Services and Prior Authorization / Notification Requirements

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Abdominoplasty — product flags vary by line; Criteria/Medical Policy: Medical Policy 083; Eff Date: 8/15/16.

Back surgery (including spinal fusion, laminectomy, vertebroplasty, kyphoplasty, etc.) — product flags vary by line; Criteria/Medical Policy: EviCore; Eff Date: 7/1/15.

Bone growth stimulator (electrical) placement — Commercial and Medicare Advantage marked; Criteria/Medical Policy: EviCore; Eff Date: 7/1/15.

Bone-anchored hearing aids (BAHA) — Commercial, Medicare Advantage and Cigna-linked marked; Criteria/Medical Policy: InterQual; Eff Date: 7/1/15.

Cardiac imaging and other cardiology services — Commercial/Medicare/Cigna-linked marked (check code for PA requirement); Criteria/Medical Policy: EviCore; Eff Date: 9/1/18.

Advanced imaging (CT, MRI, PET, SPECT) — Commercial/Medicare/Cigna-linked marked; Criteria/Medical Policy: EviCore; Eff Date: 8/1/18.

Home health services (including hourly nursing) — product-line specific flags; Criteria/Medical Policy: InterQual; Eff Date: 7/1/15.

Psychological testing — Authorization required if testing exceeds 6 hours (4 hours for pre-procedure testing); Criteria/Medical Policy: Medical Policy 224; Eff Date: 7/1/15.

Spinal stimulator trial and placement — Criteria/Medical Policy: EviCore; Eff Date: 7/1/15.

Transplantation (solid organ and stem cell) — Commercial/Medicare/Cigna-linked marked; Criteria/Medical Policy: Medical Policy 129; Eff Date: 7/1/15.

Medical Drugs (medical benefit) — Authorization required; codes available via Prior Authorization Code Lookup (all codes on PA list no later than effective date).

Authorization/coverage criteria summary

The document lists many categories and indicates whether they are on the PA/notification list for specific product lines and references the applicable medical policy or criteria source.

Medical Drugs (by therapeutic class) — Many drug categories are listed with product-line flags; status: covered_with_criteria; note: entries reference the Prior Authorization Code Lookup and associated medical policies/criteria sources.

Gene therapy / Chimeric Antigen Receptor / Retinal gene therapies — Listed and tied to specific medical policies and review vendors (OncoHealth/InterQual); status: covered_with_criteria.

Devices and DME (e.g., bone growth stimulators, compression devices, external defibrillators, continuous glucose monitors) — Product-line specific PA/notification indicated; Criteria sources: EviCore, InterQual; status: covered_with_criteria.

Specialty agents (monoclonal antibodies, complement inhibitors, immunomodulators, etc.) — Many specialty drug classes appear on the list and reference Medical Policy 215 and related policies; status: covered_with_criteria.

Example device/service entries

Selected items and their authorization flags by line of business (examples from this part of the list):

Bone growth stimulators — Criteria/Medical Policy: EviCore/InterQual; Eff Date: 7/1/15; product-line flags vary in master list.

Formula (enteral) amino-acid based — Commercial marked X; Criteria/Medical Policy: Member's Evidence of Coverage (EOC); Eff Date: 6/1/18; requires prior authorization for applicable lines.

Example device/service entries (continued)

Additional examples:

Continuous glucose monitoring devices — Medicare Advantage marked X; Criteria/Medical Policy: InterQual; Eff Date: 1/1/23.

High frequency chest wall oscillation air-pulse generator system — Commercial and Cigna-linked marked X; Criteria/Medical Policy: InterQual; Eff Date: 7/1/15.

Codes and Coding Rules

Medical Drugs (medical benefit)NDC

Medical benefit medication codes are available via the Prior Authorization Code Lookup (requires login).

Medical benefit medication codes (lookup required)mixed

Prior Authorization Code Lookup referenced for specific medication codes

DME/prosthetic codes (unlisted/misc)mixed

unlisted DME/prosthetic codes

Non-specific, miscellaneous, and unlisted prosthetic and DME codes require prior authorization as indicated

Enteral formulasNDC

enteral amino-acid based formula

Amino-acid based enteral formulas require prior authorization for applicable lines

inv-09: Psychological testing duration — Authorization required for psychological testing in excess of 6 hours (4 hours for pre-procedure testing)

Authorization thresholdAuthorization required for psychological testing in excess of 6 hours (4 hours for pre-procedure testing).

Applicable product linesCommercial and Cigna-linked plans marked X; Medicare Advantage not marked in the table for this entry.

Referenced policyMedical Policy 224 is cited as the criteria or medical policy for psychological testing.

Effective dateEffective Date for this entry = 7/1/15 as shown in the list.

What Providers Must Do

Prior Authorization

Prior Authorization required for non-contracted providers / Notification for admissions and discharges

Prior Authorization is required for ALL SERVICES provided by NON-CONTRACTED providers except where noted (for example, use of out-of-network benefits in PPO and POS products), unless otherwise listed below. See Endnotes for plan-specific exceptions. Notification is required for admissions to contracted hospitals for medical, surgical, and behavioral health services (observation status does NOT require notification). Notification is also required for contracted hospice programs (inpatient and outpatient). Notification is required for DISCHARGE from all facilities. All notifications and prior authorizations are subject to concurrent review when applicable.

Prior Authorization required for ALL SERVICES by non-contracted providers (except noted PPO/POS out-of-network benefits).
Notification required for admission to contracted hospitals for medical, surgical, and behavioral health services (observation status does NOT require notification).
Notification required for contracted hospice programs (inpatient and outpatient).
Notification required for discharge from all facilities.

Prior Authorization

Prior Authorization required for facility admissions

Prior Authorization is required for admission to the following facility types and programs. These admissions may be subject to concurrent review and must meet medical necessity criteria.

Long-term Acute Care (LTAC) admissions require Prior Authorization.
Rehabilitation facility admissions require Prior Authorization.
Skilled Nursing Facility (SNF) admissions require Prior Authorization.
Behavioral health/substance abuse residential admissions require Prior Authorization.
Partial hospitalization program admissions require Prior Authorization (NOTE: does NOT include IOP and office visits to contracted providers).

Prior Authorization

Medical drugs prior authorization and code lookup

Medical benefit drugs require prior authorization. To view the current list of medical drug codes that require authorization, log in to the Provider Portal and use the Prior Authorization Code Lookup (Pre-Auth Check). Clinical criteria or applicable medical policies (for example, OncoHealth, InterQual, Medical Policy 215, 219) may apply.

Use the Provider Portal 'Pre-Auth Check' / Prior Authorization Code Lookup for line-of-business specific code requirements.
Medical drug prior authorization lists are maintained and updated; codes shown reflect the PA list effective dates.
Clinical criteria and Medical Policies (e.g., OncoHealth, InterQual, Medical Policy 215/219) may apply to authorization decisions.

Prior Authorization

DME and device authorization/notification (select examples)

Certain durable medical equipment, devices, and supplies require prior authorization or notification. Refer to the PA list and applicable criteria for specific items and codes. Examples include bone growth stimulators, select compression devices, external defibrillators and related equipment, enteral amino-acid based formula, continuous glucose monitoring devices, and selected high-frequency chest wall oscillation systems. Criteria sources include InterQual, EviCore, Member Evidence of Coverage, and plan-specific medical policies.

Bone growth stimulators — see criteria (EviCore / InterQual).
Select compression devices — InterQual criteria apply.
External defibrillators and related equipment (including wearable/vest defibrillators) — InterQual criteria apply.
Enteral amino-acid based formula — Member's Evidence of Coverage rules apply.
Continuous glucose monitoring devices — InterQual criteria; may vary by line of business.
High-frequency chest wall oscillation systems — InterQual criteria; may be limited to certain products or lines of business.
Non-specific, miscellaneous, and unlisted prosthetic and DME codes often require prior authorization; review varied criteria.

Note

Prior authorization/notification requirements and referenced criteria

This list identifies items that require prior authorization or notification and references the applicable clinical criteria or medical policy sources. All services must be medically necessary and meet Baylor Scott & White Health Plan coverage criteria where applicable. Newly published or emerging codes/services not listed may still require prior authorization to determine medical necessity — check with Baylor Scott & White Health Plan before providing these services.

Referenced criteria/medical policy sources include InterQual, EviCore, OncoHealth, specific Medical Policies (e.g., 215, 219), and the Member's Evidence of Coverage.
Benefits are determined by each member's plan; claims will be reviewed for eligibility, benefit availability, and evidence of coverage.
The PA list is generally updated biannually but may change at any time — refer to the current version on the Provider Portal.

Note

Notification for care coordination

Baylor Scott & White Health Plan requests notification for certain services to support discharge planning, care coordination, and case management. Notifications help facilitate appropriate transitions of care and should be submitted when listed services are provided. All notified services must be medically necessary and appropriate and meet coverage criteria.

Notify the plan to assist with discharge planning, care coordination, and case management for services listed on the PA/Notification list.
All notifications are reviewed against medical necessity and member benefit provisions.
Contact the Health Services Department or Medical Directors for assistance if coverage questions arise.

Note

How to request prior authorization and access criteria

How to request prior authorization and access clinical criteria: Prior authorization requests and clinical criteria are available via the Provider Portal and by phone. For specific code-level PA requirements use the 'Pre-Auth Check' button on the Provider Portal. Contact numbers: 1-844-655-5200 for Medicare lines of business; 1-888-316-7947 for all other lines of business. To request copies of clinical criteria by fax or mail, call 1-866-334-3141 (Medicare) or 1-800-321-7947 (all other lines). For providers contracted with Cigna but not BSWHP, prior authorization requests should be directed to Cigna at 1-866-494-4872 per Endnotes.

Use the Provider Portal 'Pre-Auth Check' / Prior Authorization Code Lookup for code-specific requirements.
Phone support: 1-844-655-5200 (Medicare lines) or 1-888-316-7947 (all other lines).
To request clinical criteria via fax or mail: 1-866-334-3141 (Medicare) or 1-800-321-7947 (all other lines).
For services by providers contracted with Cigna (but not BSWHP), contact Cigna for prior authorization at 1-866-494-4872.

Definitions and Criteria Sources

inv-18: Prior Authorization — definition / short entry

DefinitionPrior Authorization: a requirement that certain services be authorized by the plan prior to delivery (see list).

PurposeTo determine medical necessity and confirm benefit eligibility before services are provided.

ApplicabilityApplies across product lines as indicated on the Notification/Prior Authorization List; non-contracted providers are subject to PA for all services except specified exceptions.

inv-19: Notification — definition / short entry

DefinitionNotification: provider informs the plan of admissions, discharges, or certain services to assist with discharge planning, care coordination, and case management.

When requiredNotification required for admission to contracted hospitals for medical, surgical, behavioral health services (Observation status does NOT require Notification).

Discharge requirementNotification is required for discharge from all facilities as noted in the list and endnotes.

inv-20: Prior Authorization Code Lookup — guidance to look up codes for PA

GuidanceUse the Prior Authorization Code Lookup (requires provider portal login) to view the current list of medical benefit medication codes subject to authorization.

NoteAll codes for each medication category were placed on the PA list no later than the effective date shown in the document.

AccessPrior authorization requests and access to clinical criteria are available via the provider portal and phone numbers referenced in the document.

inv-21: Criteria sources — examples of external criteria (InterQual, OncoHealth, EviCore) used to determine authorization requirements

Examples of external criteriaInterQual — used for services such as lung volume reduction surgery, compression devices, and other device/DME reviews.

Examples of external criteriaEviCore — referenced for musculo-skeletal, joint, and pain management services and bone growth stimulators.

Examples of external criteriaOncoHealth — referenced for certain oncology and specialty drug reviews alongside InterQual in the drug sections.

inv-22: Prior authorization — short/duplicate entry (document contains multiple reference points)

Prior authorization requirementThe listed services require prior authorization by Baylor Scott & White Health Plan; check the Notification/Prior Authorization List for item-specific flags.

Biannual updatesThe list is generally updated biannually but may change at any time; refer to the current version on the provider site.

Non-contracted providersPrior Authorization is required for all services provided by non-contracted providers except specified exceptions (see policy).

inv-23: Notification (provider informs plan to assist with discharge planning, care coordination, case management) — definition

Definition and purposeNotification: provider informs the plan so the plan can assist with discharge planning, care coordination, and case management; all services must be medically necessary and meet coverage criteria.

ScopeApplies to admissions and discharges as indicated on the Notification/Prior Authorization List; observation status does not require notification for admissions to contracted hospitals.

Endnote guidanceClaims will be reviewed to determine member eligibility at time of service; newly published codes or emerging technologies may still require prior authorization—contact the plan before providing such services.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyNotification and Prior Authorization requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2023

Next Review DateN/A

Key ActionPrior Authorization is required for ALL SERVICES provided by non-contracted providers unless using out-of-network benefits in PPO/POS products.

SourceLink

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