Prior Authorization Requirements List
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This document lists services that require prior authorization from CareSource Georgia for members and providers; it governs which services need authorization to be covered under member plans. It affects CareSource Georgia members and their providers seeking benefits for listed services.
No material clinical or coverage changes in this revision.
Prior Authorization Coverage Criteria
Prior Authorization Criteria
Covered services that require prior authorization. Authorization must be obtained before non‑emergency services are rendered; emergency services are exceptions.
ALL of the following
Includes any of the following
- All Medical Inpatient Care (acute, skilled nursing facility, inpatient rehabilitation/therapy, long term, respite care, inpatient hospice).
- Out‑of‑network services (excluding emergency services).
- Transplant evaluations and all transplant services including related transportation, lodging, and donor search fees.
- Some elective surgeries (outpatient and inpatient).
- Medical Supplies, Durable Medical Equipment (DME), and Appliances: all custom equipment; all miscellaneous or unspecified codes (example: E1399); cochlear implants (including replacements); cranial remodeling helmets; donor milk; LVAD; oral appliances for obstructive sleep apnea; enteral nutrition and supplies; patient transfer systems/Hoyer lifts; phototherapy beds; power wheelchair repairs; prosthetics/specified orthotics; speech generating devices; spinal cord stimulators; wheelchairs and some accessories; all rental/lease items (including CPAP/BiPAP, NPPV machines, apnea monitors, ventilators, hospital beds, specialty mattresses, high frequency chest wall oscillators, cough assist devices, pneumatic compression devices, infusion pumps); and wound Vacs.
- Radiology: advanced imaging including CT, CTA, MRI, MRA, PET scans; myocardial perfusion imaging (MPI); MUGA scans; echocardiography (transthoracic/transesophageal); stress echocardiography; nuclear cardiology.
- Pharmacy: some covered prescription drugs require prior authorization (PA), may have quantity limits (QL), or step therapy (ST). Non‑formulary drugs always require a formulary exception review and approval to be covered.
- Pain management procedures including epidural steroid injections, trigger point injections, implantable pumps/stimulators, and facet/sacroiliac procedures.
- Miscellaneous: reconstructive and/or potential cosmetic services (eg, rhinoplasty, breast reduction, most limb deformities, cleft lip and palate), bariatric/gastric obesity surgery, clinical trials, some radiation/oncology services, some genetic and laboratory tests, gender dysphoria services (including gender transition surgeries), hyperbaric oxygen therapy, non‑emergent ground and air transportation (including facility transfers), oral surgery that is dental in origin, sleep studies outside the home setting, applied behavioral analysis (ABA).
ALL of the following
- Maternity stays require prior authorization if the stay exceeds specified length‑of‑stay thresholds.
- Thresholds: vaginal delivery > 48 hours; cesarean delivery > 96 hours.
Coding and Length-of-Stay Rules
| E1399 | Miscellaneous DME code example listed as always requiring prior authorization |
Provider Requirements and Authorization Triggers
Obtain prior authorization for listed and out-of-network non-emergent services
Providers must obtain prior authorization for the services listed in this policy to establish medical necessity; out-of-network non-emergency services also require prior authorization and failure to obtain authorization may result in denial of reimbursement. Emergency services are exceptions.
- Prior authorization must be obtained before services are rendered for coverage.
- Out-of-network services require prior authorization except for emergency services; failure to authorize may result in denial of reimbursement.
Prior authorization required for all medical inpatient care
All medical inpatient care requires prior authorization, including acute inpatient, skilled nursing facility, inpatient rehabilitation/therapy, long-term and respite care, and inpatient hospice.
- Authorization is required for all inpatient stays to determine medical necessity.
- Includes acute, SNF, inpatient rehab/therapy, long term, respite, and inpatient hospice.
Obtain authorization if maternity stay exceeds 48 hr (vaginal) or 96 hr (cesarean)
Prior authorization is required when maternity inpatient stays exceed the specified length-of-stay thresholds: greater than 48 hours for vaginal delivery or greater than 96 hours for cesarean delivery.
- Authorization required if stay exceeds 48 hours for vaginal delivery.
- Authorization required if stay exceeds 96 hours for cesarean delivery.
Authorization required for DME, supplies, and unspecified/miscellaneous codes (e.g., E1399)
Durable medical equipment, medical supplies, and appliances listed require prior authorization, including all custom equipment, miscellaneous/unspecified codes (example: E1399), cochlear implants (including replacements), LVADs, wheelchairs, and all rental/lease items.
- All custom equipment and miscellaneous/unspecified codes (e.g., E1399) always require prior authorization.
- Specific items requiring authorization include cochlear implants (and replacements), cranial remodeling helmets, LVAD, wheelchairs and associated accessories, wound Vacs, and all rental/lease items (e.g., CPAP/BiPAP, ventilators, hospital beds).
Prior authorization for behavioral health: inpatient, residential, PHP/IOP after 5 days, and TMS
Behavioral health services require prior authorization, including all inpatient stays, residential treatment (mental health and SUD), partial hospital program (PHP) and intensive outpatient program (IOP) services after 5 days per calendar year, and transcranial magnetic stimulation (TMS).
- All inpatient behavioral health stays require authorization.
- PHP and IOP require prior authorization after 5 days per calendar year for both mental health and SUD.
- Residential treatment services and TMS require authorization.
Obtain prior authorization for advanced imaging and specified radiology services
Advanced imaging and other specified radiology services require prior authorization, including CT, CTA, MRI, MRA, PET scans, myocardial perfusion imaging (MPI), MUGA scans, and echocardiography (transthoracic/transesophageal) and stress echocardiography; nuclear cardiology procedures also require authorization.
- Advanced imaging: CT, CTA, MRI, MRA, PET.
- Cardiac imaging: MPI, MUGA scans, echocardiography (TTE/TEE), stress echocardiography, and nuclear cardiology.
Follow pharmacy PA, quantity limits, step therapy, and non‑formulary exception processes
Some covered prescription drugs require prior authorization (PA), may have quantity limits (QL), or require step therapy (ST); non‑formulary drugs always require a formulary exception review and approval prior to coverage.
- Look for PA, QL, or ST designations on the Prescription Drug Formulary and use the Find My Prescriptions tool.
- Non‑formulary drugs require a formulary exception review requested by the member, authorized representative, or prescribing physician.
Prior authorization required for pain management procedures and implants
Pain management procedures and implanted pain devices require prior authorization, including epidural steroid injections, trigger point injections, implantable pain pumps, implantable spinal cord stimulators, facet/sacroiliac joint procedures, sacroiliac joint fusion, and facet joint interventions.
- Obtain authorization prior to performing injections, implantable device placement, or joint fusion/intervention procedures for pain management.
Obtain authorization for reconstructive/cosmetic, gender dysphoria, bariatric, clinical trials, hyperbaric therapy, and non‑emergent transport
Reconstructive and cosmetic services, gender dysphoria surgeries, bariatric surgery, clinical trials, hyperbaric oxygen therapy, non‑emergent transport, and other listed miscellaneous services require prior authorization or are excluded/limited per the policy.
- Includes reconstructive/cosmetic procedures (e.g., rhinoplasty, breast reduction, cleft lip/palate), gender transition surgeries, bariatric/gastric obesity surgery, and clinical trials.
- Non-emergent ground and air transportation requires prior authorization (including between facilities).
Key Definitions
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