Prior authorization requirements

Behavioral health

Services billed with the following revenue codes always require prior authorization:

0240 to 0249 — All-inclusive ancillary psychiatric
0901, 0905 to 0907, 0913, 0917 — Behavioral health treatment services
0944 to 0945 — Other therapeutic services
0961 — Psychiatric professional fees

Fax all requests for services that require prior authorization to:

Inpatient: 1-844-430-6806
Outpatient: 1-844-442-8012

Pharmacy

Services billed with the following revenue codes always require prior authorization:

0632 — Pharmacy multiple sources

Pharmacy resources:

Medicare

Prior authorization is not required for physician evaluation and management services for members enrolled in Medicare Advantage.

Long-term services and supports

All services billed with the following revenue codes:

0023 — Home health prospective payment system
0570-0572, 0579 — Home health aide
0944-0945 — Other therapeutic services
3101-3109 — Adult day and foster care

All long-term services and supports require prior authorization. Please use the following contact information to submit your requests.

Submit LTSS prior authorization requests

Phone:
1-877-440-3738

Elective services

Elective services provided by or arranged at nonparticipating facilities always require prior authorization.