--Prior Authorization is required for the following:
AUTH MUST BE ISSUED PRIOR TO VISIT FOR EACH SPECIFIC PROCEDURE NEEDED.
--Prior Authorization or PCP Referral is required for SOME procedures for the following:
** Medicare does not issue authorization for any injection; however, documentation must show medical necessity.
** Medicare does not issue authorization; however, written scripts given to pt’s must include:
Pt Name, DOB, Proc Needed, Diag Code & if test is needed with or without contrast.
- Division of the Blind
- Veterans Administration
- Vocational Rehab (appointments can only be booked by their staff, not by patients)
- Tricare Prime (needs referral from PCP for any “medical” visits, pt must request fromPCP)
AUTH MUST BE ISSUED PRIOR TO VISIT FOR EACH SPECIFIC PROCEDURE NEEDED.
--Prior Authorization or PCP Referral is required for SOME procedures for the following:
- HMO plans (regardless of the insurance company) – some HMO’s require PCP referral, some procedures require prior authorization (i.e. plugs, lasers, injections, etc.)
** Medicare does not issue authorization for any injection; however, documentation must show medical necessity.
- < >Eylea, Jetrea, Lucentis, Macugen & Ozurdex:Billing MUST be notified– precertification may be required (every insurance plan is different)
- All other injections:Please check with billing.Auth requirements vary depending on the insurance company & the patient’s individual plan.
** Medicare does not issue authorization; however, written scripts given to pt’s must include:
Pt Name, DOB, Proc Needed, Diag Code & if test is needed with or without contrast.
- Most other insurance companies require Prior Authorization for radiology tests.Please complete appropriate paperwork and notify billing.Also, please find out what facility the patient would like the test performed at. (Or at least what area of town they prefer.) Place of service IS required to get an authorization.
| policy_protocol_authorization_guidelines_fec_01292013.docx |