Obtain prior authorization before providing listed services

Providers must obtain prior authorization for services listed in this policy before rendering care; failure to obtain prior authorization may result in a denial of reimbursement. Emergency services are an exception and do not require prior authorization. Services must conform to all plan terms and conditions, including eligibility, medical necessity, coverage restrictions, and benefit limitations; refer to the member's Evidence of Coverage for details.

• Prior authorization required before services are rendered for listed items
• Failure to obtain prior authorization may result in denial of reimbursement
• Emergency services are exceptions to the prior authorization requirement
• Services must meet plan terms (eligibility, medical necessity, coverage restrictions, benefit limits)

Verify eligibility and understand authorization is not payment assurance

Verify member eligibility and benefits before providing services; the provider is responsible for this verification. Note that an authorization only indicates that criteria were met at review and does not guarantee payment for the service.

• Providers are responsible for verifying eligibility and benefits prior to service
• Prior authorization is not a guarantee of payment

Common service categories requiring prior authorization

Obtain prior authorization for high-level categories of services that routinely require review, including all medical inpatient care, certain elective surgeries, transplant-related services, and many durable medical equipment and supplies.

• All Medical Inpatient Care (acute, skilled nursing facility, inpatient rehabilitation/therapy, respite when receiving hospice, inpatient hospice)
• Some elective surgeries (outpatient and inpatient)
• Transplant evaluations and all transplants including related services (e.g., transportation, lodging, donor search fees)
• Durable Medical Equipment and supplies listed as always requiring authorization (e.g., custom equipment, unspecified codes such as E1399, LVAD, wheelchairs, rental/lease items)

Maternity: prior authorization for early scheduled deliveries and extended stays

For maternity care, obtain prior authorization for scheduled deliveries before 39 weeks gestation and for hospital stays that exceed the stated length-of-stay thresholds. Specifically, stays that exceed 48 hours for vaginal delivery or 96 hours for cesarean delivery require prior authorization.

• Scheduled delivery < 39 weeks requires prior authorization
• Length-of-stay prior authorization triggers: >48 hours for vaginal delivery, >96 hours for cesarean delivery