CurrentBlue Cross Blue Shield - MainePolicy N/A
Services Requiring Prior Authorization (Ohio MyCare Plan)
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Lists physical and behavioral health services that require prior authorization, notifications, or do not require authorization for Anthem Blue Cross and Blue Shield MyCare Ohio members; intended for providers and administrative staff managing prior auth for covered members.
Policy Summary
PayerBlue Cross Blue Shield - Maine
PolicyServices Requiring Prior Authorization (Ohio MyCare Plan)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateJan 1, 2026
Next Review DateN/A
Key ActionObtain prior authorization for listed physical and behavioral health services before scheduling or delivering those services.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
multipleservice categories
30 visitsvisit threshold
20 hourspsych testing threshold
48 hrsnotification window
Services Requiring Prior Authorization and Notifications
Physical prior authorization criteria
Service-level coverage stance and requirements
ALL of the following
- Elective air ambulance.
- All out-of-network services, apart from emergency services.
- All services that may be considered experimental and/or investigational.
- All services not listed on the Ohio Department of Medicaid Fee Schedule.
- All unlisted miscellaneous and manually priced codes, including but not limited to codes ending in 99.
- All inpatient hospital admissions (medical, surgical, skilled nursing, long‑term acute, and rehabilitation services).
- Obstetrical admissions and newborn deliveries exceeding 48 hours after vaginal delivery and 96 hours after cesarean section.
- Any newborn that transfers from newborn nursery to a higher level of care (NICU, acute inpatient care, or transitional care nursery).
- Inpatient transfers to new acute care facilities.
- Medical detoxification.
- Long‑term care initial placement while enrolled with the plan (up to 90 days).
- Acupuncture — prior authorization required after 30 visits.
- Chiropractic care — prior authorization required after 30 visits for ages less than 21 and after 15 visits for ages 21 or older.
- Cochlear implantation.
- Durable medical equipment (DME) rentals, purchases, and custom equipment.
- DME, prosthetics, and orthotics.
- Diapers/pull‑ups: 200 per month for individuals over 21 years old.
- Negative pressure wound therapy.
- Elective procedures including but not limited to joint replacements, laminectomies, spinal fusions, discectomies, vein stripping, and laparoscopic/exploratory surgeries.
- Gastric restrictive procedures and surgeries.
- Speech, occupational, and physical therapy — prior authorization required after 30 visits (applies to private and outpatient facility‑based services).
- Surgical services that may be considered cosmetic (examples include blepharoplasty, mastectomy for gynecomastia, mastopexy, panniculectomy, penile prosthesis, plastic surgery/cosmetic dermatology, reduction mammaplasty, septoplasty, gender reassignment services).
- Genetic testing.
- Hyperbaric oxygen.
- Home‑based services (see details): home healthcare and skilled nursing after 18 combined visits regardless of modality; home infusion services (HCPCS codes per pharmacy list); home health aide; private duty nursing; hospice inpatient services.
- Hysterectomy — Hysterectomy Consent Form required.
- Cardiac and pulmonary rehabilitation.
- Pain management including external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation, and nerve blocks.
- Pharmacy and medications per prior authorization list.
- Transplants (non‑kidney) must be requested directly from the appropriate consortium.
Radiology and behavioral health criteria
Outpatient radiology and behavioral health prior authorization
ALL of the following
- Radiology outpatient services requiring prior authorization (when performed as outpatient services): CTA, CCTA, CT, ECHO, MRA, MRI, MPI, PET, MUGA.
ALL of the following
- Behavioral health services requiring prior authorization: Mental health and/or SUD inpatient hospitalizations for adults 21 and older.
- Psychological and neuropsychological testing when there are more than 20 hours/encounters of all psychological testing codes per calendar year.
- Therapeutic Behavioral Services Group Per Diem — authorization required when rendering more than one group per diem service per day by a different billing agency.
- Assertive community treatment.
- Behavioral analysis therapy.
- SUD partial hospitalization program (ASAM 2.5).
- SUD residential treatment (ASAM 3.1, 3.5, 3.7) with the following rules: first and second admissions in a calendar year require notification; 31+ days during either admission requires prior authorization and medical necessity review; third and subsequent admissions in a calendar year require prior authorization and medical necessity review.
- Urine drug screen — authorization required only when more than 30 presumptive drug screens or more than 12 definitive drug tests are provided within a benefit year.
Notification criteria
Notification requirements
ALL of the following
- All newborn deliveries require notification.
- Maternity obstetrical services after the first visit and outpatient care (including observation) require notification.
- Anthem MyCare requires notification of all emergent inpatient admissions within 48 hours of admittance.
No prior authorization required
Services that do not require prior authorization
Physical services not requiring prior authorization
- Emergency room services (in‑network and out‑of‑network).
- 48‑hour observations (except maternity observations — notification required).
- Low‑level plain films (X‑rays, EKGs).
- Family planning services (in‑network and out‑of‑network).
- Post‑stabilization services (in‑network and out‑of‑network).
- Women’s healthcare/OB‑GYN services.
- Routine vision services.
- Dialysis.
- Post‑operative pain management if a surgical procedure is performed on the same date of service.
- Services given at school‑based clinics.
- Primary care provider (PCP) services.
- Local health department services.
Behavioral health services not requiring prior authorization
- Individual, family, multiple‑family, and group psychotherapy for mental health and SUD.
- Psychotherapy for a mental health and/or SUD crisis.
- Behavioral health counseling.
- Psychosocial rehabilitation services.
- Individual and group community psychiatric supportive treatment.
- Therapeutic Behavioral Services Group Per Diem — authorization required when rendering more than one group per diem service per day by a different billing agency.
- SUD assessment, individual and group counseling, and case management.
- SUD peer support services up to four hours per day.
- Evaluation and management visits for mental health and SUD (including home and prolonged visits).
- Psychiatric diagnostic evaluation.
- Smoking and tobacco cessation counseling.
- Screening, brief intervention, and referral to treatment (SBIRT).
- Depression screening and cognitive behavioral health therapies provided in coordination with the Help Me Grow program, including services performed in the home.
Codes, Thresholds, and Visit Limits
Code categories requiring prior authorization or manual pricingmixed
| unlisted codes ending in 99 | All unlisted miscellaneous and manually priced codes (including codes ending in 99) require prior authorization or manual pricing review. |
| HCPCS (home infusion) | Home infusion HCPCS codes listed in pharmacy prior authorization list require prior authorization. |
Visit thresholds for prior authorization — acupuncture, therapy, chiropractic, home health
AcupuncturePrior authorization required after 30 visits.
Outpatient speech/occupational/physical therapyPrior authorization required after 30 visits (applies to private and outpatient facility-based services).
Chiropractic carePrior authorization required after 30 visits for members under age 21 and after 15 visits for members age 21 or older.
Home health (combined visits)Prior authorization required after 18 combined visits, regardless of modality (home healthcare and skilled nursing).
Psychological testing prior authorization threshold
Psychological/neuropsychological testing thresholdPrior authorization required when there are more than 20 hours/encounters of all psychological testing codes per calendar year.
Related behavioral ruleThis threshold applies to combined psychological and neuropsychological testing codes across the calendar year.
Authorization triggerExceeding 20 hours/encounters in a calendar year prompts prior authorization and medical necessity review.
What Providers Must Do
Documentation Required
Prior authorization process reference
See Anthem MyCare Ohio Provider Manual for the prior authorization process.
Prior Authorization
Prior authorization required for listed services
Providers must obtain prior authorization for the listed physical and behavioral health services before rendering or scheduling care when specified in this policy.
- Elective air ambulance; all out-of-network services (except emergencies); services considered experimental/investigational; services not on the Ohio Medicaid Fee Schedule; unlisted/manual priced codes (including codes ending in 99).
- All inpatient hospital admissions (medical, surgical, SNF, LTAC, rehabilitation); certain obstetrical admissions/newborn transfers; inpatient transfers to new acute care facilities; medical detoxification; long-term care initial placement (up to 90 days while enrolled).
- Specific procedures and therapies (e.g., cochlear implantation; DME rentals/purchases/custom equipment; negative pressure wound therapy; elective procedures such as joint replacements and spinal surgeries; gastric restrictive procedures; speech/OT/PT after 30 visits; acupuncture after 30 visits; chiropractic care after thresholds).
- Radiology outpatient services (CTA, CCTA, CT, ECHO, MRA, MRI, MPI, PET, MUGA) and behavioral health services (adult MH/SUD inpatient for 21+, psychological/neuropsych testing >20 hours/year, TBS group per diem when >1 group/day by different billing agency, assertive community treatment, behavioral analysis therapy, SUD partial hospitalization and residential levels as specified).
Documentation Required
Notification required for newborns and emergent inpatient admissions
Notification (not full prior authorization) is required for all newborn deliveries and for emergent inpatient admissions within 48 hours of admittance.
- Maternity obstetrical services after the first visit and outpatient care, including observation, require notification.
- Anthem MyCare requires notification of all emergent inpatient admissions within 48 hours of admittance.
Note
Services not requiring prior authorization
The following services do not require prior authorization; providers may deliver these services without obtaining prior authorization.
- Emergency room services (in-network and out-of-network) and post-stabilization services.
- 48-hour observations (except maternity observations which require notification).
- Low-level plain films (X-rays, EKGs).
- Family planning services; women's healthcare/OB-GYN services; routine vision services; dialysis.
- Post-operative pain management if performed on the same date as surgery; services at school-based clinics; primary care provider services; local health department services.
Key Definitions and Home-Based Service Rules
Elective air ambulance — prior authorization requirement
Policy statementElective air ambulance requires prior authorization.
ScopeApplies to elective (non-emergent) air ambulance services listed under physical health services requiring prior authorization.
Home-based services — prior authorization thresholds
Home healthcare (home visits)Prior authorization required after 18 combined visits for home healthcare and skilled nursing, regardless of modality.
Home infusionHome infusion services require prior authorization; see pharmacy list of HCPCS codes that require prior authorization.
Home health aide and private duty nursingPrior authorization applies to home health aide services and private duty nursing (extended nursing services).
Hospice inpatient servicesHospice inpatient services are included among home-based services that require prior authorization per policy.
Policy Summary
PayerBlue Cross Blue Shield - Maine
PolicyServices Requiring Prior Authorization (Ohio MyCare Plan)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateJan 1, 2026
Next Review DateN/A
Key ActionObtain prior authorization for listed physical and behavioral health services before scheduling or delivering those services.
SourceLink
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