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ABMG_Prior_Auth_w_Auth_Types_Effective_7.1.2010 Powered By Docstoc
					                                                                        Prior Authorization List
                                                                         Effective July 1, 2010

                                             Procedure/Service                                                         ABMG CARE Authorization Type
Ablation (Cardiac), Cryo Ablation                                                                                     Outpatient/Office Services
Abortions (CPT's 59840 vs. 59841) (for services NOT provided by EB Perinatal Group)                Done in office     Outpatient/Office Services
                                                                                                   Done in facility   Outpatient Surgery
Acupuncture                                                                                                           Outpatient Rehab
AICD checks/maintenance (facility based only)                                                                         Outpatient/Office Services
Alcohol/Drug Rehab (Carved out service - call member's Health Plan)
Allergy Injections/Antigen (for Blue Cross members only)                                                              Outpatient/Office Services
Allergy Testing (for Blue Cross members only)                                                                         Outpatient/Office Services
Ambulance, non-emergency transfers and air ambulance
Amniocentesis (for office based services NOT provided by EB Perinatal Group and NON office based                      Outpatient/Office Services
Angiogram                                                                                                             Diagnostic Testing
Aortogram                                                                                                             Diagnostic Testing
Aphakic Lens                                                                                                          DME/Orthotics/Prosthetics
Aquatic Therapy                                                                                                       Outpatient Rehab
Arteriogram                                                                                                           Diagnostic Testing
Arthroscopy                                                                                                           Outpatient Surgery
Artificial Insemination (non-office based services)                                                                   Outpatient/Office Services
Assisted Reproductive Surgery (ART) infertility                                                                       Outpatient/Office Services
Audiogram/Hearing Eval/Hearing Aid Eval (for Blue Cross and Blue Shield members only)                                 Outpatient/Office Services
Audiology-Routine (for Blue Cross and Blue Shield members only)                                                       Outpatient/Office Services
Autologus Blood Donation                                                                                              Outpatient/Office Services
Avonex                                                                                                                Drugs Requiring Authorization
Baclofen Pump Trial/Refill/Maintenance                                                                                Outpatient/Office Services
Bariatric Consult and Surgery                                                                      Consult            Outpatient/Office Services
                                                                                                   Surgery            Hospital Admission
Behavioral/Developmental Pediatric (for services provided by Children First IPA)                                      Outpatient/Office Services
Betaseron                                                                                                             Drugs Requiring Authorization
Biofeedback                                                                                                           Outpatient Rehab
Biopsies, in office (dermatological)                                                                                  Outpatient/Office Services
Biopsies, OP/Interventional radiology (facility based services)                                                       Outpatient/Office Services
Bone Density Studies (DEXA)                                                                                           Diagnostic Testing
Bone Scan (for Blue Cross and Blue Shield members only)                                                               Diagnostic Testing
Botox injections                                                                                                      Drugs Requiring Authorization
Brachytherapy                                                                                                         Outpatient/Office Services
BRCA Testing                                                                                                          Diagnostic Testing
Breast biopsies (facility based)                                                                                      Outpatient Surgery
Breast Reconstruction/Reduction                                                                                       Outpatient Surgery
Bronchoscopy                                                                                                          Outpatient/Office Services
Burn therapy/treatment                                                                                                Outpatient/Office Services
Cancer Center (drug, procedures, surgery)                                                          Drugs              Drugs Requiring Authorization
                                                                                                   Surgery            Outpatient Surgery
                                                                                                   Diagnostic         Diagnostic Testing
Cardiac Cath Placement                                                                                                Outpatient Surgery
Cardiac Rehab                                                                                                         Outpatient Rehab
Catheter/Port placement/removal/declotting                                                                            Outpatient/Office Services
Chemical Dependency treatment                                                                      Outpatient         Outpatient/Office Services
                                                                                                   Inpatient          Hospital Admission
Chemotherapy-Outpatient                                                                                               Outpatient/Office Services
Children First IPA providers for members 16 years of age and older                                                    Outpatient/Office Services
Chiropractic Services                                                                                                 Outpatient Rehab
Cholangiopancreatography (ERCP)                                                                                       Outpatient Surgery
Chorionic Villus Sampling (CVS) (for services NOT provided by EB Perinatal Group)                                     Outpatient/Office Services
Colonoscopy                                                                                                           Outpatient Surgery
Copaxone                                                                                                              Drugs Requiring Authorization
Coronary Sinus Angiogram                                                                                              Diagnostic Testing
Cosmetic Surgery                                                                                   Done in office     Outpatient/Office Services
                                                                                                   Outpatient         Outpatient Surgery
                                                                                                   Inpatient          Hospital Admission
CPAP consults at the Sleep Lab                                                                                        Outpatient/Office Services
C-Sections, elective                                                                                                  Hospital Admission
CT Scans Head/Neck (Carotid)                                                                                          Diagnostic Testing
Dental Appliances for Sleep Apnea                                                                                     DME/Orthotics/Prosthetics
Dental (Oral) Surgery                                                                              Done in office     Outpatient/Office Services
                                                                                                   Outpatient         Outpatient Surgery

July 1, 2010                                                                                                                                          1 of 3
                                                                          Prior Authorization List
                                                                           Effective July 1, 2010

Depo-Provera                                                                                                     Drugs Requiring Authorization
Dermatology Services                                                                                             Outpatient/Office Services
Detox-Inpatient                                                                                                  Hospital Admission
Diabetic Testing supplies                                                                                        DME/Orthotics/Prosthetics
Dialysis                                                                                                         Outpatient/Office Services
Dialysis-Out of Area                                                                                             Outpatient/Office Services
DME                                                                                                              DME/Orthotics/Prosthetics
DME- Supplies (colostomy and diabetic)                                                                           DME/Orthotics/Prosthetics
EMG/Nerve Conduction Studies (facility based only)                                                               Diagnostic Testing
Enbrel Drug                                                                                                      Drugs Requiring Authorization
Endoscopy (EGD)                                                                                                  Outpatient Surgery
Epogen/Epoetin/Procrit                                                                                           Drugs Requiring Authorization
EPS-Electrophysiology Studies                                                                                    Outpatient/Office Services
Erection Devices                                                                                                 DME/Orthotics/Prosthetics
Event Monitor (Cardiac)                                                                                          Outpatient/Office Services
Evoked Auditory/Visual Brainstem testing                                                                         Outpatient/Office Services
Family Practice OB Care                                                                                          Hospital Admission
Fetal Echo (ultrasound)                                                                                          Diagnostic Testing
Fiducial Seed Marker Placement                                                                                   Outpatient/Office Services
FISH assay testing                                                                                               Diagnostic Testing
Genetic Counseling & Associated Testing                                                                          Outpatient/Office Services
Growth Hormone                                                                                                   Drugs Requiring Authorization
Hearing Aids                                                                                                     DME/Orthotics/Prosthetics
Heart Scans                                                                                                      Diagnostic Testing
Hepatitis A, > 18 years of age                                                                                   Vaccines Requiring Authorization
Her2Nu Testing                                                                                                   Diagnostic Testing
Home Health                                                                                                      Home Care Services
Home Lab Draws                                                                                                   Home Care Services
Home X-Rays                                                                                                      Home Care Services
Hospice                                                                                                          Home Care Services
HUAM (home uterine activity monitoring)                                                                          Home Care Services
Hyperbaric Chamber                                                                                               Outpatient/Office Services
Hypnosis                                                                                                         Outpatient/Office Services
Incision & Drainage (facility based only)                                                                        Outpatient Surgery
Infertility Tx, Advanced (i.e. GIFT, ZIFT, IVF, FET, Embryo Freezing) for services NOT provided by Dr. Willman
or Dr. Hinkley                                                                                                   Infertility
Injectables                                                                                                      Drugs Requiring Authorization
(IMRT) - Intensity Modulated Radiation Therapy                                                                   Outpatient/Office Services
Inpatient Surgery                                                                                                Hospital Admission
Insulin Pump/supplies                                                                                            DME/Orthotics/Prosthetics
Interferon                                                                                                       Drugs Requiring Authorization
Interventional Radiology                                                                                         Outpatient/Office Services
IUD (Intrauterine device)                                                                                        Outpatient/Office Services
Intravenous immunoglobin (IVIG)                                                                                  Drugs Requiring Authorization
Intravenous Pyelogram (IVP)                                                                                      Diagnostic Testing
Investigational/Experimental procedures (Clinical Trials)                                                        Use Applicable Authorization Type

Lab for Pediatric members > 2 years at CHO                                                                       Diagnostic Testing
Laryngoscopy                                                                                                     Outpatient Surgery
Lithotripsy (ESWL)                                                                                               Outpatient Surgery
Lovenox                                                                                                          Drugs Requiring Authorization
Lupron                                                                                                           Drugs Requiring Authorization
Lymphedema therapy/treatment                                                                                     Outpatient/Office Services
Massage Therapy                                                                                                  Outpatient Rehab
Medical Supplies (if not dispensed by office)                                                                    Outpatient/Office Services
Mental Health, IP or OP ( Secure Horizon only- for Initial consult with Bay Psychiatric Associates and all Non
Bay Psychiatric services) Call the health plan for non-Secure Horizons members.                                  Outpatient/Office Services
Methotrexate                                                                                                     Drugs Requiring Authorization
MOHs surgery                                                                                                     Outpatient/Office Services
MRA                                                                                                              Diagnostic Testing
MRI (All MRI's)                                                                                                  Diagnostic Testing
Myelogram                                                                                                        Diagnostic Testing
Myocardio Perfusion Study                                                                                        Outpatient/Office Services
Myofunctional Therapy                                                                                            Outpatient Rehab
Nuchal Translucency                                                                                              Diagnostic Testing
Neupogen                                                                                                         Drugs Requiring Authorization
Neuropsych Testing                                                                                               Outpatient/Office Services
OB Care                                                                                                          Hospital Admission
Occupational Therapy                                                                                             Outpatient Rehab

July 1, 2010                                                                                                                                        2 of 3
                                                                           Prior Authorization List
                                                                            Effective July 1, 2010

Oncology office visits, Commercial members                                                                         Outpatient/Office Services
Oncology office visits after 3 visits, Senior members (First 3 visits are Direct Referral from PCP)                Outpatient/Office Services
Out of Network provider consults                                                                                   Outpatient
Oral Device                                                                                                        DME/Orthotics/Prosthetics
Orthotics                                                                                                          DME/Orthotics/Prosthetics
Out Of Network Surgery                                                                                Outpatient   Outpatient Surgery
                                                                                                      Inpatient    Hospital Admission
Outpatient Surgery                                                                                                 Outpatient Surgery
Oxygen Treatment Initial                                                                                           DME/Orthotics/Prosthetics
Oxygen-Therapy Continued                                                                                           DME/Orthotics/Prosthetics
Oxygen-Travel                                                                                                      DME/Orthotics/Prosthetics
Pain Management                                                                                                    Outpatient/Office Services
Pallative Care                                                                                                     Outpatient/Office Services
Paracentesis                                                                                                       Outpatient/Office Services
Pelvic Floor Therapy                                                                                               Outpatient Rehab
PET Scans                                                                                                          Diagnostic Testing
Phototherapy for hyperbilirubinemia(Bili Lights/Blanket)                                                           DME/Orthotics/Prosthetics
Phototherapy (PUVA)                                                                                                Outpatient/Office Services
Physical Therapy (for non-Capitated services)                                                                      Outpatient Rehab
Pilates Therapy                                                                                                    Outpatient Rehab
Procrit                                                                                                            Drugs Requiring Authorization
Psychiatric Care-Partial Hosp. Program ( for Secure Horizons members only)                                         Outpatient/Office Services
Psychological testing                                                                                              Outpatient/Office Services
PTCA                                                                                                               Hospital Admission
Pulmonary Rehab                                                                                                    Outpatient Rehab
Radiation Therapy                                                                                                  Outpatient/Office Services
Rebetron                                                                                                           Drugs Requiring Authorization
Respite Care                                                                                                       Home Care Services
Sandostatin                                                                                                        Drugs Requiring Authorization
Sclerotheraphy                                                                                                     Outpatient/Office Services
Second Opinion (In network)                                                                                        Specialist Referral
Second Opinion (Out of Network)                                                                                    Specialist Referral
Self injectable Medication                                                                                         Drugs Requiring Authorization
Sigmoidoscopy (facility based only)                                                                                Outpatient/Office Services
Sign Language Interpretation                                                                                       Outpatient/Office Services
Skilled Nursing Facilities                                                                                         Hospital Admission
Sleep Studies (polysomnography)                                                                                    Diagnostic Testing
Sonorex                                                                                                            Outpatient/Office Services
Speech Therapy                                                                                                     Outpatient Rehab
Stress Management Resources                                                                                        Outpatient/Office Services
Surgery, Inpatient                                                                                                 Hospital Admission
Surgery, Outpatient                                                                                                Outpatient Surgery
Swallowing Evaluation/Study (for Blue Cross and Blue Shield members only)                                          Outpatient/Office Services
Sweat Test                                                                                                         Diagnostic Testing
Synagis                                                                                                            Drugs Requiring Authorization
Synvisc (Hyalgan)                                                                                                  Drugs Requiring Authorization
Thoracentesis                                                                                                      Outpatient/Office Services
TMJ surgery                                                                                                        Outpatient Surgery
Trabeculectomy                                                                                                     Outpatient Surgery
Transfusions                                                                                                       Outpatient/Office Services
Transplants                                                                                                        Hospital Admission
Transportation                                                                                                     Ambulance Services
Ultrasound-guided biopsy                                                                                           Outpatient/Office Services
Uterine Artery Embolization                                                                                        Outpatient/Office Services
Vascular Rehabilitation                                                                                            Outpatient Rehab
Vasectomy                                                                                                          Outpatient Surgery
Vasectomy, Non-Scalpel method                                                                                      Outpatient Surgery
Vasectomy Reversal                                                                                                 Outpatient Surgery
Venous evaluation, mapping, stripping                                                                              Outpatient/Office Services
Vestibular Rehab                                                                                                   Outpatient/Office Services
Vitamin B12 injections (for services not provided by PCP)                                                          Drugs Requiring Authorization
Venous Reflux                                                                                                      Outpatient/Office Services
Wound Care                                                                                                         Outpatient/Office Services
Whole Body Scan                                                                                                    Diagnostic Testing

July 1, 2010                                                                                                                                       3 of 3

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