HM Medical Clinic

Microsoft word - fhca auth list_4-16

Medical Prior Authorization List
For prescription drug requirements, see plan formularies.
See Separate List for Florida Hospital & Rosen Employees. Effective April 15, 2016
General Information
 These requirements are administered by Health First Health Plans ("Health Plan").
 Benefits are determined by the plan. Items listed may have limited coverage, or not be covered at all.
 All items and services on this list require prior authorization, regardless of the service location, plan type, or
provider participation status.  Referrals are not required for network specialist care. Refer to the current Provider Directory or visit our website for a list of network providers.  Authorization is not a guarantee of payment. Coverage is subject to member eligibility, as well as applicable benefit and provider contract provisions on the date of service. Contract limitations may apply and supersede any authorization provided.  This document is updated periodically, but may change at any time. Please refer to the current version by visiting our website at myFHCA.org.  See the Authorization List Code Reference for potentially-applicable procedure codes. The list is available on our website. Codes are for reference only, are not all-inclusive, and are subject to change.  If waiting for a decision in the standard timeframe could seriously harm the member's life, health, or ability to regain maximum function, an expedited process is available.  Yellow highlights indicate changes from last version. How to Request Authorization
 With the following exceptions, authorization requests should be submitted directly to the Health Plan.  High Tech Imaging, Echocardiograms, and Sleep Disorder Testing and Treatment are authorized
by AIM Specialty Health (AIM). Visit aimspecialtyhealth.com to request authorization and to access
guidelines.
 Behavioral Health and Substance Abuse Services are authorized by Magellan Behavioral Health,
Inc. (Magellan). Authorization may be requested by phone toll-free at 1.800.424.HFHP (4347) or online
at magellanprovider.com.
 To request authorization from the Health Plan, submit the appropriate medical or pharmacy (drug) "Authorization Request" form or request authorization online. Include applicable codes, patient identification, and clinical information to support the request. IMPORTANT CONTACTS FOR AUTHORIZATIONS SUBMITTED TO THE HEALTH PLAN
 Submit online requests via your secure account at myFHCA.org/myportal
 Fax medical authorization requests to: 1.855.328.0059
 Fax drug authorization requests to: 1.855.328.0061
 For questions, call Customer Service toll-free at 1.844.522.5278 Monday through Friday from 8 a.m. to 6

Hospital/Skilled Nursing Facility
Hospital Admissions
 Contracted hospitals:
 All procedures included on this List require prior authorization.  All inpatient admissions require authorization (including hospice for Commercial members).  Health First hospital admissions require notification only.  Outpatient admissions do not require authorization unless the procedure itself requires it.  Non-Contracted Hospitals:
 All procedures included on this List require prior authorization.  All inpatient and outpatient admissions require authorization (including hospice for Commercial  Admissions for Labor and Delivery do not require prior authorization. Authorization is needed if
baby is admitted for medical care.  Behavioral Health/Substance Abuse Services: Inpatient and outpatient hospital services (including
Partial Hospitalization and Intensive Outpatient Programs) require authorization by Magellan. See "How to Request Authorization" for information. Skilled Nursing Facility (SNF) Services
 Inpatient SNF Services
 Outpatient Services During a Non-Covered Stay
 Covered services such as physician, diagnostic, and rehab services provided during a custodial stay. Diagnostic Testing
Laboratory Services
 Genetic Testing, except standard Down Syndrome and Cystic Fibrosis screening
 CologuardTM for colorectal cancer screening
Radiology Services
 Outpatient High Tech Imaging (MRI/MRA, CT, PET) – Authorized by AIM. See "How to Request
Authorization" for information.  Computed tomographic (CT) colonography (virtual colonoscopy)
 DaTscan SPECT Imaging to diagnose Parkinson's
 Echocardiograms - Authorized by AIM Specialty Health. (Fetal echos do not require prior authorization.)
 Cardiac Loop Recorder Implantation
 Orthopantograms (Panoramic X-Rays)
Other Diagnostic Services
 Mobile Cardiac Outpatient Telemetry (MCOT)
 Psychological Testing – Authorized by Magellan. See "How to Request Authorization" for information.
 Sleep Testing – Authorized by AIM. See "How to Request Authorization" for information.
 Infertility Diagnostic Services
 M2A Capsule Endoscopies
Investigational Items and Services
 Any item or service potentially considered investigational or experimental must be authorized in advance,
including Category B Investigational Devices covered by Medicare. Investigational services may be described by temporary Category III CPT Codes, but may be assigned a CPT or other HCPCS code. Contact us with questions. Y0089_MPINFO3875 (03/14)

Medical Equipment/Prosthetics/Orthotics

 Bone Growth Stimulators (External)
 Cochlear Implants/ Auditory Brainstem Implants/ Bone Anchored Hearing Aids
 Continuous Glucose Monitoring – Long-Term; Authorization not required for 72-hour monitoring
 Customized DME (reported with HCPCS code K0900)
 Diabetic Test Supplies – Non-Preferred (any supplies other than Abbott's Freestyle Lite, Freedom Lite, or
 Elastic Garments, Belts, Sleeves or Coverings; Authorization not required for lymphedema sleeves.
 Enteral/Parenteral/Oral Nutrition
 External Defibrillator (i.e. The Vest)
 Home PT/INR Monitor
 Hospital Beds (All)
 Lymphedema Pumps
 Neurostimulators
 Orthotics - See Code Reference for details. Some items may be provided in certain locations or by certain
specialties without authorization. Noncovered orthotics (e.g. foot orthotics) do not require authorization.  Oscillatory Devices for Airway Clearance, i.e. The Vest, Intrapulmonary Percussive Ventilation (IPV)
 External Prosthetic Devices [not including post-cancer breast prostheses]
 Positive Airway Pressure Devices (e.g. CPAP, BIPAP, APAP) – Authorized by AIM every 90 days during
first year of use. See "How to Request Authorization" for information. Authorization not required for supplies.  Quantities in Excess of Medicare Guidelines
 Seat/Patient Lift Mechanisms
 Scooters
 Snore Guards (Oral Appliances)
 Noninvasive ventilator (e.g. Trilogy Vent)
 Wheelchairs and Accessories

Physical, Occupational and Speech Therapy Services
 Children Under 9 Years of Age
 Prior authorization required for all therapy services except the initial evaluation.  Individuals 9 Years of Age or Older
 Prior authorization is required for more than 20 physical, occupational, or speech therapy visits per calendar year. (Each discipline considered separately.) Spinal Procedures
 Total Disc Arthroplasties, including removal
 Spinal Instrumentation
 Removal of Posterior Segmental
 Kyphoplasties/Vertebroplasties
 Laminectomies
 Thermal Intradiscal Procedures (TIPS)
 Spinal Fusion
Y0089_MPINFO3875 (03/14)

Other Surgical Services
 Bariatric Surgery, and any surgical procedure (i.e. hernia repair) performed with an obesity surgery
 Bronchial Thermoplasty
 Intacs for Keratoconus
 Implantation Services associated with devices that require prior authorization
 Penile Implants
 Reconstructive Procedures
 DIEP flap breast reconstruction requires prior authorization. Other post-cancer breast reconstruction procedures do not require authorization.  Reduction Mammoplasty
 Sleep Apnea/Snoring Surgery
 Transcatheter Aortic Valve Replacement (TAVR)
Select Items and Services
 Ambulance Services: Non-Emergency Transportation
 Autism Services
 Autologous Chondrocyte Implant
 Chronic Care Management (Medicare only)
 Dental/Maxillofacial Services
 EECP (Enhanced External Counterpulsation)
 Home Births (Planned)
 Incontinence Procedures including sacral nerve stimulation, tibial nerve stimulation, Renessa®.
 Organ Transplant Services
 Proton Beam Therapy
 Radiopharmaceutical, therapeutic, not otherwise classified
 Skin/Wound Care (No authorization required for negative pressure wound therapy.)
 Skin (dermal) substitutes, i.e. AlloSkin  Electrical stimulation and electromagnetic  PUVA, laser treatment therapy for non-healing wounds  Superficial Radiation Therapy
 Varicose Vein Treatment
Behavioral Health - Authorized by Magellan. See "How to Request Authorization".
 Electroconvulsive Therapy
 Substance Abuse Services – Inpatient, Partial Hospitalization Program (PHP), and Intensive Outpatient
Program (IOP) services Out-of-Network Services
HMO Members
 With the exception of emergency care, urgently-needed care outside the service area, or renal dialysis for Medicare members, all OON services require prior authorization. POS/PPO Members (Plans with out-of-network benefits)
 All items and services on this list require authorization, regardless of the plan type. See separate Authorization List for Florida Hospital Employees. 

Medical Drugs Requiring Prior Authorization (Drugs covered as medical benefits)
 Intravenous Immune Globulins (not required for macular degeneration or retinal edema w/ trial of Avastin in prior 12 months.)  DECA-DURABOLIN  Viscosupplements (not required for macular degeneration or retinal edema w/ trial of Avastin in prior 12 months.)  Orphan Drugs
Drugs with an "orphan" designation require prior Florida Hospital Care Advantage is administered by Health First Health Plans. Health First Health Plans is an HMO plan with a Medicare contract. Enrollment in Health First Health Plans depends on contract renewal. Y0089_MPINFO3877FH (03/14) See separate Authorization List for Florida Hospital Employees.

Source: http://www.greatweightoff.com/fhca/providers/forms/auth_list.pdf