Additional Outpatient, Imaging, Therapy, DME, Behavioral Health, Pharmacy and Vendor Requirements
Additional outpatient, imaging, therapy, DME, behavioral health outpatient, pharmacy, transportation, and vendor-provided services have distinct prior authorization, notification, and utilization requirements summarized below. Providers should follow these rules to avoid denials and ensure proper billing.
Outpatient Surgery Prior Authorization: Specific outpatient surgical procedures require prior authorization when listed (examples include bariatric surgery, blepharoplasty, breast reconstruction, certain skin surgery codes when performed in ambulatory surgery centers). Some procedures performed within 24 hours are typically not approved as inpatient and, when performed in-network as outpatient, do not require authorization.
Behavioral Health Outpatient Services Authorization: Effective 01/01/2020, in-network, in-state outpatient SUD services (office visits, therapy/counseling visits, outpatient clinic visits for SUD, intensive outpatient programs, outpatient rehabilitation, and opioid treatment programs) do not require prior authorization. Out-of-state or out-of-network providers must request authorization.
Outpatient and DME Services Authorization: Durable medical equipment and certain outpatient services require prior authorization when their codes are listed in Appendix I or when otherwise specified (including DME provided by outside vendors).
Imaging Authorization: Advanced imaging and other imaging services require prior authorization when listed or when delegated to a vendor (e.g., TurningPoint). Providers should confirm delegated code lists and prior authorization processes.
Therapy Services Authorization and Visit Limits: Physical, occupational, and speech therapy services may require prior authorization and are subject to visit limits when specified by the code lists or benefit plan. Authorization requirements apply when listed in Appendix I or delegated to a vendor.
Therapeutic and Other Procedure Authorization: Specified therapeutic procedures, injections, and other procedure codes require prior authorization (examples include certain joint injections and other procedures noted in the outpatient surgery list).
Chiropractic Services: Chiropractic treatment requires prior authorization when codes are listed in Appendix I or when required by benefit design.
Counseling Services / Diabetes Self-Management Training (DSMT): Counseling and DSMT services require authorization when identified in the code lists or when performed out-of-network; in-network outpatient behavioral health counseling for SUD is not subject to prior authorization per the OASAS rules above.
Services Provided by Outside Vendors: Services and devices for which prior authorization has been delegated (for example, TurningPoint Healthcare Solutions) require authorization through the delegated vendor. Associated device HCPCS codes linked to delegated CPT codes will also be reviewed by the delegated vendor for medical necessity.
Transportation: Non-emergent medical transportation requires prior authorization when specified by the member’s benefit plan or when listed in Appendix I; emergency transportation and emergent services do not require prior authorization.
Pharmacy and Enteral Therapy: Prescription drugs, specialty pharmacy, and enteral nutrition products require authorization when listed on the formulary or in Appendix I or when identified in the plan’s pharmacy prior authorization rules. Step therapy and quantity limits applicable to pharmacy items must be followed as published in pharmacy benefit materials.