Services and procedures requiring prior authorization
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This document lists services, procedures, providers, and settings that require prior authorization from Health Alliance Plan (HAP) and provides guidance on where providers should submit authorization requests. It applies to HAP members, providers, and facilities submitting requests for covered services.
Services Requiring Prior Authorization
Prior Authorization Required
Services require prior authorization when they fall into any of the listed categories.
Refer to the online Procedure Reference Lists (hap.org) or CareAffiliate for specific requirements and submission portals.
The list of services and procedures requiring prior authorization in this document is not all-inclusive. Coverage limitations or exclusions may apply based on the member's subscriber documents (Schedule of Benefits, Subscriber Contract, Member Benefit Guide, or Evidence of Coverage for Medicare Advantage), specific provider type, or place of service. Providers should verify applicable exclusions and limits in the member's subscriber documents and the plan's Procedure Reference Lists.
This policy functions as administrative guidance that identifies services and procedures that require prior authorization from HAP. It is intended to direct providers to the plan's Procedure Reference Lists and authorization portals for submission and detailed requirements, and does not establish clinical medical‑necessity criteria or treatment guidelines.
Coding and Thresholds
| No codes listed |
What Providers Must Do
Prior Authorization Required
Prior authorization is required for listed inpatient admissions, facility services (SNF, rehabilitation, LTAC), and many procedures. Providers must obtain authorization before scheduling or admitting members for these services to avoid delays or denials.
- Some inpatient admissions (surgical and nonsurgical)
- Skilled nursing facility, rehabilitation facility, Long Term Acute Care (LTAC)
- Non-emergency behavioral inpatient, residential behavioral health, partial behavioral programs
- Certain procedures and services listed on the Procedure Reference Lists (e.g., musculoskeletal procedures, bariatric, high-tech imaging)
Specialty Medication Authorization
Certain specialty medications and classes require prior authorization. This includes many medical injectable and specialty medications across multiple conditions — authorization must be obtained through the appropriate specialty/drug review vendor or via the HAP authorization process.
- Affected conditions / product categories (not all inclusive): Hereditary Angioedema (HAE), Cystic Fibrosis, Pulmonary Arterial Hypertension (PAH), Inborn Errors of Metabolism and Rare Diseases, Respiratory Syncytial Virus (RSV) prevention, Corticotropins, Asthma biologics, Alpha-1-antitrypsin deficiency therapies, Autoimmune disease biologics, Multiple Sclerosis therapies, Cancer therapies, Hemophilia factors, IVIG, Osteoporosis/osteoarthritis injectables
Submission Instructions
Submit authorization requests and check requirements before rendering services. Use hap.org Procedure Reference Lists and the designated vendor portals for clinical review and prior authorization decisions.
- Log in at hap.org and select Procedure Reference Lists under Quick Links
- EviCore provider portal: https://www.evicore.com/resources/healthplan/hap (used for high-tech imaging, pain management, many surgical/procedural reviews)
- TurningPoint provider portal: https://www.myturningpoint-healthcare.com/ (used for specified musculoskeletal/other services)
- Enter requests in CareAffiliate/CareAffinity by selecting Authorizations from the home page — system will indicate if internal review is required
Risk of Denial Without Authorization
Failure to obtain required prior authorization may result in claim denial or non-coverage. Providers are responsible for verifying authorization requirements and confirming approvals before providing services to members.
- Claims for services requiring prior authorization may be denied if authorization was not obtained
- Verify member coverage and authorization requirements via hap.org or the vendor portals prior to service
- Non-contracted and out-of-network services require prior authorization and may be denied if not authorized
Admission Criteria for Facilities
SNF | LTACH | IRF | hospital — Admission Criteria
Continued Stay Criteria for Facilities
SNF | LTACH | IRF | hospital — Continued Stay Criteria
Discharge Criteria
The document provides no explicit discharge clinical criteria for facility settings. For Skilled Nursing Facility (SNF), Long‑Term Acute Care (LTAC), Inpatient Rehabilitation Facility (IRF), and hospital stays, providers must follow the member's subscriber documents and the plan's Procedure Reference Lists for specific discharge and coverage rules.
Key Definitions
Policy Background
This policy identifies services and procedures that require prior authorization. Examples listed include some inpatient admissions (surgical and nonsurgical), Skilled Nursing Facility, Rehabilitation Facility, Long Term Acute Care (LTAC), non‑emergency and residential behavioral health stays, partial behavioral health programs, non‑contracted and out‑of‑network providers, pain management (including anesthesia), musculoskeletal procedures, sleep studies, and DME greater than $1500. For full details and submission instructions, providers should consult the Procedure Reference Lists on hap.org.
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