CurrentCareSourcePolicy H9712 MI-MMP-M-3043197a

Prior Authorization List — HAP CareSource MI Health Link

Lists health care services that require prior authorization from HAP CareSource MI Health Link for members; applies to in-network and out-of-network providers and affects Medicare-Medicaid Plan (MI Health Link) enrollees in Michigan.

Policy Summary

PayerCareSource

PolicyPrior Authorization List — HAP CareSource MI Health Link

Policy CodePolicy H9712 MI-MMP-M-3043197a

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders must obtain prior authorization from HAP CareSource MI Health Link before members receive listed services; emergency care is exempt.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~60+services listed that may require prior authorization

PIHPbehavioral health routing

No PAassessments exempt from PA

Member Servicescontact

Services Requiring Prior Authorization

Required Prior Authorization Items

Policy Summary

PayerCareSource

PolicyPrior Authorization List — HAP CareSource MI Health Link

Policy CodePolicy H9712 MI-MMP-M-3043197a

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders must obtain prior authorization from HAP CareSource MI Health Link before members receive listed services; emergency care is exempt.

SourceLink

On This Page

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ALL of the following

All medical inpatient care (acute, skilled nursing facility, long term and respite care, inpatient rehabilitation/therapy, inpatient hospice)
All out-of-network services
Transplant services (heart, lung, stem-cell, liver, pancreas)
Some elective surgeries and procedures that may be considered cosmetic (examples: abdominoplasty, otoplasty/ear graft, rhinoplasty, chemical exfoliation, vein procedures, mandible/maxilla reconstruction)
Bariatric services
All unproven, experimental or investigational items and services (life‑threatening illness exceptions may apply)
Some genetic testing and laboratory services
Gender reaffirmation surgeries or services
Penile prosthesis
Hyperbaric oxygen therapy
Some durable medical equipment (examples: hospital beds, wheelchairs, shoe inserts, batteries, gradient pressure sleeves/gauntlet/glove, bathroom assistive devices, enteral nutrition and supplies, pneumatic compression devices)
Spinal cord stimulators
Cardiac diagnostic and implantable procedures
Arthroscopies/arthroplasties
Cochlear implants
Tumor excision/biopsy
Services for temporomandibular joint (TMJ)
Non-emergent ground and air transportation between facilities
Tissue-engineered skin substitutes
Some vision and hearing services
Personal care services
Community transition services
Medical injectable and specialty medications for conditions including but not limited to cancer, osteoporosis, osteoarthritis, immunodeficiencies (IVIG), hemophilia factors, hereditary angioedema, inborn errors of metabolism and rare disease, respiratory syncytial virus prevention, corticotropins, cystic fibrosis, asthma, pulmonary arterial hypertension, alpha-1-antitrypsin deficiency, autoimmune disease

Behavioral Health Prior Authorization

Behavioral health services are reviewed separately through Pre-Paid Inpatient Health Plans (PIHP):

ALL of the following

Partial hospitalization program (PHP) services
All inpatient behavioral health stays
Individual psychotherapy
Group psychotherapy
Opioid treatment program (OTP) services
Substance use disorder (SUD) services

Home Care and Outpatient Therapy

Home care and outpatient therapy prior authorization rules:

ALL of the following

Home health services (home health aide visits, skilled nurse visits, social worker visits) require prior authorization except assessments/evaluations
Occupational, physical, and speech therapy provided in the home require prior authorization except assessments/evaluations
Outpatient therapies (occupational therapy, physical therapy, speech therapy, cognitive rehabilitation therapy) require prior authorization for habilitative and/or rehabilitative services; initial assessments/evaluations do not require prior authorization

Radiology Prior Authorization

Radiology and diagnostic imaging that require authorization include examples below; providers must verify coverage:

ALL of the following

CT, CTA, MRI, MRA, PET scans
Myocardial perfusion imaging (MPI) and MUGA scans
Echocardiography (transthoracic and transesophageal), nuclear cardiology, and stress echocardiography
Phototherapy
Providers are responsible for verifying member eligibility and benefits before providing services; authorization is not a guarantee of payment.

Provider Responsibilities and Authorization Notes

Prior Authorization

Prior Authorization Required

Providers must obtain prior authorization from HAP CareSource MI Health Link before members receive the services listed in this policy. Emergency care does not require prior authorization. Prior authorization helps ensure services are appropriate and medically necessary.

Applies to services listed under Radiology and Outpatient Therapies where specified
If provider is out-of-network, the provider or member must obtain prior authorization to avoid potential non-reimbursement

Documentation Required

Eligibility and Payment Note

Providers are responsible for verifying member eligibility and benefits before delivering services. An approved authorization does not guarantee payment — services must also meet plan terms including eligibility, medical necessity, coverage restrictions, and benefit limits.

Verify eligibility and benefits with HAP CareSource MI Health Link prior to scheduling services
Authorization approval is not a guarantee of payment

Note

Assessment Exception — No Authorization for Evaluations

No prior authorization is required for assessments or evaluations related to home care services and outpatient therapies (including occupational, physical, and speech therapy) — initial assessments/evaluations to determine need are exempt from prior authorization.

Home Care Services: home health aide, skilled nurse, social worker, occupational therapy, physical therapy, speech therapy — assessments/evaluations do not require prior authorization
Outpatient Therapies: occupational, physical, speech, cognitive rehabilitation — assessments/evaluations do not require prior authorization

Key Terms

Prior authorization

DefinitionApproval from HAP CareSource MI Health Link required before a service is provided (except emergency care).

PurposeEnsures care is appropriate and necessary before the member receives listed services.

When requiredProviders must obtain prior authorization from HAP CareSource MI Health Link before members receive the services listed in this document; emergency care is exempt.

Out-of-network noteIf a provider is not part of the HAP CareSource MI Health Link network, the provider or member must obtain prior authorization or approval before services are provided to be covered.

Payment caveatAuthorization does not override the need to meet plan terms (eligibility, medical necessity, coverage restrictions and benefit limitations).

In-network provider

DefinitionA provider that participates in the HAP CareSource MI Health Link network.

Member requirementTo have health care services covered by HAP CareSource MI Health Link, members must use in-network providers except as otherwise permitted (e.g., emergency services).

Out-of-network impactIf a provider is not in-network, the member or provider must obtain prior authorization or approval before services are provided; failure to do so may result in non-reimbursement.

Network coordinationHAP CareSource MI Health Link works with certain doctors and providers to deliver care; in-network participation enables coverage under the member's plan.

OpenPayer

Prior Authorization List — HAP CareSource MI Health Link

Services Requiring Prior Authorization

Radiology and Procedure Codes

Provider Responsibilities and Authorization Notes

Key Terms

CT	CT
CTA	CTA
MRI	MRI
MRA	MRA
PET	PET scans
MPI	Myocardial perfusion imaging (MPI)
Phototherapy	Phototherapy
MUGA	MUGA scans
Echocardiography	Echocardiography (transthoracic/transesophageal)
Nuclear cardiology	Nuclear cardiology