Services and procedures requiring prior authorization
Customize your policy alerts
Sign up for all Health Alliance Plan (HAP) policy alerts
Know when Health Alliance Plan (HAP) releases new policies or updates existing guidance.
Monitor payer policy activity
This document lists services and procedures that require prior authorization from Health Alliance Plan (HAP) and guides providers and members about where to request authorizations. It applies to HAP members and contracted and non-contracted providers subject to the member's benefit documents.
No material clinical or coverage changes in this revision.
Services Requiring Prior Authorization
Prior Authorization Required - Full List
Services that require prior authorization from HAP (list form):
ALL of the following
- Some inpatient admissions (surgical and nonsurgical), including skilled nursing facility, rehabilitation facility, and Long Term Acute Care (LTAC); non-emergency behavioral inpatient stays, residential behavioral health stays, and partial behavioral health programs.
- Non-contracted providers and facilities for all services (including anesthesia and behavioral health).
- All out-of-network services (including behavioral health).
- Pain management services including anesthesia.
- Musculoskeletal procedures.
- Sleep studies.
- Durable medical equipment (DME) with cost greater than $1500.> $1500
- Procedures that could be considered cosmetic (including but not limited to abdominoplasty, breast reconstruction, rhinoplasty, panniculectomy).
- High-tech imaging.
- Bariatric services.
- Cardiac diagnostic outpatient and inpatient implantable procedures (including cardiac catheterization, pacemakers, valve procedures).
- Services for TMJ (temporomandibular joint).
- Genetic testing.
- Gene therapy.
- Gender-affirming surgeries or services.
- Experimental and investigational or unproven procedures.
- Some clinical trials.
- Applied Behavioral Analysis (ABA) treatment.
- Uvulopalatopharyngoplasty, including laser-assisted procedures.
- Some chiropractic services.
- Miscellaneous or not otherwise classified (NOC) procedures.
- Some varicose vein procedures.
- Termination of pregnancy.
- Transcranial magnetic stimulation.
- Medical formulas.
- Private duty nursing.
- Diagnostic labs.
- Supplemental feedings via tube or IV.
- Medical injectable and specialty medications for conditions including (not all inclusive): cancer; osteoporosis; osteoarthritis; immunodeficiencies (IVIG); hemophilia factors; hereditary angioedema; inborn errors of metabolism and rare diseases.
This list is not all inclusive. Coverage limitations or exclusions may exist for certain members, providers and places of service; providers should verify via hap.org Procedure Reference Lists or submit authorization requests through CareAffiliate. Certain categories route through third-party vendor portals (EviCore, TurningPoint) as indicated in the Procedure Reference Lists.
The following list summarizes services and procedures that require prior authorization from Health Alliance Plan (HAP). This list is provided for provider reference but is not all inclusive. Coverage of services for Members is based on the Member's subscriber documents and is subject to all terms and conditions, including specific exclusions and limitations.
To confirm whether a specific service requires authorization, providers should verify the Procedure Reference Lists on hap.org (select Procedure Reference Lists under Quick Links) or submit the request in the CareAffiliate authorization workflow as described in HAP resources.
The document identifies "Experimental and Investigational or Unproven Procedures" as a category that requires prior authorization. The policy does not define this term within the list; providers should follow HAP authorization processes and consult the Procedure Reference Lists or contact HAP for determination and prior authorization requirements.
Coding and DME Thresholds
| No codes listed |
Provider Responsibilities and Authorization Process
Prior Authorization Required for Listed Services
A broad set of services listed below require prior authorization through HAP. Providers must check HAP's Procedure Reference Lists at hap.org or submit requests through the appropriate third‑party portals (EviCore or TurningPoint) where indicated. Failure to obtain required prior authorization may result in claim denial and member financial responsibility per the member's subscriber documents.
- Inpatient admissions (surgical and nonsurgical), skilled nursing, rehabilitation, LTAC
- Non‑contracted and out‑of‑network providers/facilities for all services
- Pain management, musculoskeletal procedures, sleep studies, DME > $1,500
- High‑tech imaging, bariatric, cardiac implantable procedures, genetic and gene therapies
- Gender affirmation, experimental/investigational procedures, some clinical trials
- Applied Behavioral Analysis (ABA), transcranial magnetic stimulation, behavioral health services per Coordinator Behavioral Health Management
- Diagnostic labs, medical injectable and specialty medications, private duty nursing, supplemental feedings
PROVIDER ACTIONS — Inventory Reference
Provider actions associated with the inventory entry: see the inventory placeholder below for the specific action text to render. This callout is a placeholder linking to the related inventory item so the final writer can include the exact provider action language from the source document.
- Reference inventory entry: inv-07 — render provider action text from source here
PROVIDER ACTIONS — Use HAP Procedure Reference Lists or Third‑Party Portals
Providers must verify authorization requirements before scheduling or performing services. Use HAP's Procedure Reference Lists (log in at hap.org and select Procedure Reference Lists under Quick Links) for services that require internal HAP review. For services managed by third parties, submit prior authorization requests through the designated portals:
- Check HAP Procedure Reference Lists at hap.org before submitting requests.
- Submit imaging, pain management, behavioral health and many specialty requests via EviCore: https://www.evicore.com/resources/healthplan/hap
- Submit musculoskeletal/orthopedic and certain procedure requests via TurningPoint: https://www.myturningpoint-healthcare.com/
- If using CareAffiliate, select Authorizations from the home page; the system will indicate if internal review is not required.
PROVIDER ACTIONS — Denial Risk for Unauthored Services
Services provided without required prior authorization may be denied. When an authorization is required but not obtained, claims may be denied and the member could be held responsible for payment in accordance with the member's subscriber documents (Schedule of Benefits, Evidence of Coverage, Subscriber Contract). Providers should obtain and document authorizations in advance to avoid denial and adverse billing consequences.
- Denial risk if prior authorization not obtained for listed services
- Potential member financial liability per subscriber documents
- Document and retain authorization references on claims submissions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.