Prior authorization requirements in the East Region

Procedures and services:

  • Adjunctive dental care
  • Advanced life support air ambulance in conjunction with stem cell transplantation
  • Bariatric surgery
  • Extended Care Health Option (ECHO) services
  • Home health services, including home infusion
  • Hospice
  • Laboratory Developed Tests (LDT)
  • Low-protein modified foods
  • Open, arthroscopic and combined hip; Surgical for the treatment of Femoroacetabular Impingement (FAI)
  • Spinal fusion and related procedures
  • Transplants (solid organ and stem cell, not corneal transplant)

Inpatient stays:

  • Acute care admissions (Notification of acute care admission is required by the next business day)
  • Admissions or transfers to Skilled Nursing Facilities (SNF), rehabilitation and Long-Term Acute Care (LTAC)
  • Continued stay review
  • Discharge notification

Behavioral health:

  • Applied Behavior Analysis (ABA)
  • Autism Care Demonstration (ACD)
  • Electroconvulsive Therapy (ECT)
  • Non-emergency admissions, to include detoxification & rehabilitation services
  • Psychoanalysis
  • Residential Treatment Centers (RTC)
  • Transcranial Magnetic Stimulation (TMS)

Behavioral health concurrent review:

  • Emergency admissions
  • Intensive Outpatient Program (IOP)
  • Opioid Treatment Program (OTP)
  • Partial Hospital Program (PHP)

List is subject to change.