Prior Authorization Requirements

Services that Require Prior Authorization

  • Ambulance Transports, non emergent (Request submitted for review with key information)
  • Bariatric services and surgery
  • Bone Density Study (DEXA)
  • Cardiac Rehabilitation
  • CT Scans
  • Colonoscopy
  • Dialysis, including port insertion/remova
  • Durable Medical Equipment (DME)
  • EMG/Nerve Conduction Studies
  • Endoscopies
  • Epidural Injections
  • Experimental/Investigational Procedures
  • Genetic Testing
  • Home Health/Hospice services
  • Hyperbaric Oxygen Treatment
  • Infusion Services, administration + drugs Injectable Drugs (partial list below) given in an Office or Outpatient setting.Anticancer chemotherapy, Botox, intravenous clotting factors & gamma globulin, travel immunizations, erythropoetin, (Epogen), Filgrastrim, G-CSF, Foscarnet, Growth hormone, Ganciclovir, HPG, intravenous immunosuppressants, Interferon.
  • Intensity Modulated Radiation Therapy (IMRT)

Lab services not listed on Lab Corp’s Requisition Form (see below)

  • Lymphedema Therapy
  • Medical Supplies (ostomy, urological)
  • MRI/MRA Scans (including Breast MRIs)
  • Nuclear Medicine
  • Orthotics/Prosthetics (includes shoe inserts)
  • Outpatient Surgery
  • PET Scans
  • Physical, Occupational, Speech Therapy
  • Psychological Testing (for medical diagnoses) See member’s Health Plan identification card for behavioral health services contact.
  • Radiation Therapy
  • Second Opinion Consultations
  • Sleep Studies
  • Transplants
  • Ultrasounds
  • Varicose Vein Ablation/Removal
  • Wound Care

Pre-Certification Authorizations

  • Admissions to Hospitals, Skilled Nursing Units (SNU) or Skilled Nursing Facilities (SNF)
  • Psychiatric admissions for United Medicare Advantage members ONLY (All other Health Plans are carved out to a separate Mental Health Carrier)

Retrospective Authorization Requests

  • Services which were rendered without prior authorization
    (Retro requests for commercial members must be submitted to Affinity within 5 days of the date of service to be considered. Per CMS Guidelines, retroactive request for Medicare Risk Members require submission of the claim and medical necessity documentation. Retrospective authorization requests should only occur on a rare occasion. The provider does run the risk of having a claim denied when prior authorization rules are not followed. In some cases, member eligibility becomes an issue and Affinity will work with the provider to review a claim under those circumstances.)

 

Provider Resources