CurrentCareSourcePolicy AR-PAS-M-1440129

Prior Authorization List

Full list of services that require prior authorization from CareSource PASSE; identifies service categories, behavioral health, home care, HCBS, medical supplies/DME, outpatient therapies, and pain management items that require prior authorization. Contains notes on medical necessity, exceptions (emergency care), and contact information for Member Services.

Policy Summary

PayerCareSource

PolicyPrior Authorization List

Policy CodePolicy AR-PAS-M-1440129

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProvider must obtain prior authorization from CareSource PASSE before providing any service on the prior authorization list, except emergency care; authorization is not a guarantee of payment.

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical coverage or prior authorization requirements in this update.

9Major service group categories listed

1Example HCPCS miscellaneous code cited

Policy Summary

CareSource PASSE requires prior authorization for a full list of services before the plan will cover them. Services must be medically necessary — meaning needed to diagnose or treat an illness, injury, condition, disease, or its symptoms — and must be included in the member's Person-Centered Service Plan (PCSP). If the PCSP cannot be updated prior to prior authorization review, the PCSP will be added or updated after the review.

The prior authorization requirement covers major categories including medical inpatient care (acute, skilled nursing facility, inpatient rehabilitation/therapy, long term and respite care), behavioral health services (for example, ABA, residential behavioral health, inpatient and outpatient behavioral health, PHP), home care and HCBS, medical supplies/DME and appliances (including miscellaneous HCPCS codes such as E1399, custom equipment, rentals), outpatient therapies (habilitation/rehabilitation services beyond initial assessments), and pain management services (for example, facet procedures, implantable spinal cord stimulators, pain pumps). The list also includes elective, experimental/unproven services, gender dysphoria surgeries, bariatric surgery, certain maternity stays, sleep studies outside the home, urine drug testing, and other items noted in the prior authorization list.

What Providers Must Do

Prior Authorization

Obtain prior authorization for listed services

Provider must obtain prior authorization from CareSource PASSE before providing any service on the prior authorization list, except emergency care; authorization is not a guarantee of payment.

Documentation Required

Medical necessity and PCSP documentation

Services must be medically necessary and included in the member's Person-Centered Service Plan (PCSP); if the PCSP cannot be updated before prior authorization review, it will be added afterward.

Denial Risk

Out-of-network provider authorization requirement

All out-of-network services require prior authorization; failure to obtain authorization may result in denial of coverage.

Documentation Required

Eligibility and benefits verification

Providers are responsible for verifying eligibility and benefits before providing services.

Billing Rule

Contact Member Services

For questions or to confirm prior authorization requirements, contact Member Services at 1-833-230-2005 (TDD/TTY: 711) Monday–Friday, 8 a.m.–5 p.m. Central Time.

Policy Summary

PayerCareSource

PolicyPrior Authorization List

Policy CodePolicy AR-PAS-M-1440129

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Prior Authorization List

Policy Summary

Prior Authorization Coverage Criteria

Code References

What Providers Must Do

Key Terms

Common Questions

Policy Changes