Participating Providers are required to submit requests for services to the Health Plan. CCHP’s Utilization Management (UM) staff reviews authorization requests and the request will either be approved or denied. UM decisions will be communicated in writing to the requesting provider and to the member. The categories that usually require additional UM review include but are not limited to:

• Services with the following place-of-service codes
  • 09 Prison
  • 21 Inpatient Hospital
  • 22 On-Campus Outpatient Hospital
  • 24 Ambulatory Surgery Center
  • 31 Skilled Nursing Facility
  • 33 Custodial Care Facility
  • 34 Hospice
  • 51 Inpatient Psychiatric Facility
  • 52 Psychiatric Facility – Partial Hospitalization
  • 56 Psychiatric Residential Treatment Center
  • 61 Comprehensive Inpatient Rehabilitation Facility
• Services provided by out-of-network providers
• All chemotherapy and high-cost drugs, including but not limited to monoclonal antibodies, immunotherapy, skin substitute, and any medications on the non-preferred drug list of the health plan’s step therapy program
• Home health and related services, outpatient occupational therapy, physical therapy, and speech therapy
• Chiropractor services
• Acupuncture services
• Others: radiology (MRIs, scans and nuclear studies), durable medical equipment (DMEs)/prosthetics/orthotics, genetic/molecular testing, hospital-based procedures, implants/stimulators, cosmetic procedures, radiation oncology, transplants, experimental/investigational requests, any codes that are not covered by Medicare
• Any codes listed in the prior authorization list

PRIOR AUTHORIZATION LIST

Auth Code Table

The list represents medical services and Part B medications (i.e., medications that are delivered in the physician’s office, clinic, outpatient, or home setting) that require authorization prior to being provided or administered. Services must be provided according to Medicare coverage guidelines and must be medically necessary, as established by the Centers for Medicare & Medicaid Services (CMS). Please contact the health plan or consult its Evidence of Coverage for confirmation of coverage.

Services or medications provided without authorization may be subject to retrospective medical necessity review. Submitting all relevant clinical information at the time of the request will facilitate a more expeditious determination. If additional clinical information is required, a health plan representative or designee will request the specific information needed to complete the authorization process. Providers can refer to the Provider Operations Manual for guidelines to submit an authorization request. Providers who participate in an independent practice association (IPA) may be subject to an IPA prior authorization list and should refer to their IPA for guidance.

Note: An approved authorization is not a guarantee of payment. Payment is based on benefits in effect at the time of service, member eligibility, and medical necessity. This list is subject to change at any time without notification.