Prior Authorization Required

Prior Authorization required for many services and medical benefit drugs. Prior authorization (PA) is required for numerous procedures, devices, and medical/drug categories listed on the Baylor Scott & White Health Plan Notification/Prior Authorization List. Use the Provider Portal tools (Pre‑Auth Check and Prior Authorization Code Lookup) to confirm code‑level PA requirements before scheduling or delivering services.

• Prior authorization required for many surgical procedures, durable medical equipment, devices, and medical‑benefit medications.
• Medical drug categories on the PA list include (but are not limited to) antineoplastic agents, immunomodulatory and immunosuppressive agents, biologics, and specialty categories routed to OncoHealth or other specialty reviewers.
• Some clinical reviews are performed by external reviewers (EviCore, InterQual, OncoHealth) per the listed medical policy references.

Prior Authorization Required for Listed Services

Prior Authorization is required for the listed services, devices, and drug categories shown on the PA list. Specific entries include admissions to LTAC, rehab and skilled nursing facilities, behavioral health residential and partial hospitalization, selected surgeries and devices (e.g., spinal procedures, VADs, bariatric surgery when covered), bone growth stimulators, certain imaging/cardiology services, and many DME items. For medical‑benefit medications, log in and use the Prior Authorization Code Lookup to view current PA codes.

• Facility admissions requiring PA: LTAC, Rehabilitation, Skilled Nursing Facilities, behavioral health residential, partial hospitalization (excluding IOP/contracted office visits).
• Selected procedures and devices (examples): spinal surgery, ventricular assist devices, left atrial appendage exclusion devices, lung volume reduction, bariatric surgery (if a covered benefit).
• DME and supplies (examples): power wheelchairs, oxygen delivery devices, ventilators, cranial remolding orthotics — many require PA and reference InterQual criteria.

Prior Authorization Requirement for Non‑Contracted Providers

Non‑contracted (out‑of‑network) providers: Prior Authorization is required for ALL services provided by non‑contracted providers to obtain full in‑network benefits except where specified (for example, certain out‑of‑network benefits in PPO and POS products and limited exceptions noted in source). Services rendered by non‑contracted providers must be authorized in advance per plan rules.

• All services by non‑contracted providers require PA to receive full in‑network benefits, with limited exceptions (e.g., some PPO/POS out‑of‑network benefit uses).
• Exceptions noted for non‑contracted Pathology, Anesthesiology, Radiology, Emergency Department and Assistant Surgeon physicians providing services in a contracted inpatient facility — follow plan rules and confirm via Pre‑Auth Check.

Benefits Verification — Authorization Is Not a Guarantee of Payment

Authorization is not a guarantee of benefits or payment. Benefit coverage and payment are determined by the member’s plan, eligibility at time of service, evidence of coverage, and claims agreements. Even with an approved authorization, claims are reviewed for eligibility and benefit availability at time of service.

• Prior Authorization does not guarantee payment — verify member benefits and coverage limitations prior to service.
• Claims will be reviewed at time of service for member eligibility and plan benefit availability; newly published codes or emerging therapies may still require PA to determine medical necessity.

Clinical Criteria Available Upon Request

Clinical criteria and medical policies are available upon request. Providers may request copies of the clinical criteria or medical policy references used for review and medical necessity determinations.

• To request clinical criteria or a copy of the medical policy used in decision making, call: 1‑866‑334‑3141 (Medicare lines) or 1‑800‑321‑7947 (all other lines).
• Use the Provider Portal (Pre‑Auth Check and Prior Authorization Code Lookup) to view line‑of‑business specific code requirements and referenced criteria online.