Provider must obtain prior authorization if required from Medical Management.
Prior authorization is not a verification of benefits, payment or eligibility. Failure
to obtain prior authorization will result in a 25% reduction in your benefits for
those services that were not prior authorized.
Prior Authorization Requirements:
- Inpatient hospitalization
- All outpatient surgical procedures - this includes all invasive procedures (for
example: colonoscopy, endoscopy, biopsy, etc.)
- Nuclear Medicine Scans such as PET/SPECT (except MRI & CT)
- Durable Medical Equipment > than $500
- Home Health Care
- Home IV Therapy
- Hospice Care
- Skilled Nursing Facility
- Outpatient Surgery
- Dialysis
- Chemotherapy / Radiation
- Cardiac & Pulmonary Rehab
- Corrective Appliances/Prosthesis
- Physical Therapy, Occupational Therapy, Speech Therapy
- Biotech * (See Below)
- Wound Treatment
- Sleep Study
- Pain Management
- Ground and Air Ambulance
- Transplants
Behavioral Health Prior Authorizations:
Behavior Health is through Midwest Behavior Health: 1-800-223-6246.
* Pharmacy Prior Authorizations:
Many prescription drugs will require prior authorization before any benefits will
be payable under the plan. Biotech medication request will be completed by
InformedRx:
InformedRx Prior Authorization Contact Information:
- Phone: 1-800-626-0072
- Fax: 1-866-511-2202
