Services that Require Prior Authorization for Children s Rehabilitative Services Effective 10/1/13

Transcription

1 Services that Require Prior Authorization for Important Information: Any Specialty Care service rendered outside of the MSIC for conditions listed on the CRS Master Diagnosis List () requires prior authorization. List can be found at: Primary Care Services under the AHCCCS Acute Care benefit for CRS Fully Integrated and CRS Partially Integrated-Acute members do not require prior authorization when provided by a CRS contracted provider. Behavioral Health Services under the AHCCCS Behavioral Health benefit for CRS Fully Integrated and CRS Partially Integrated-BH members do not require prior authorization, unless listed below, and when provided by a CRS contracted provider. ALL services rendered by a non-contracted provider require authorization and must have supporting documentation to support the out of network request. Any service which may be considered Experimental or Investigational is not a covered benefit. The following directives apply to all CRS Prior Authorizations: The member must be eligible at the time the covered service is rendered. Only one service may be requested per Physicians Services Requisition (PSR) form. Authorization is not a guarantee of payment. ALL rendering providers/facilities/vendors must be actively AHCCCS registered. Important Reminders: All services must be covered benefits as outlined by the Arizona Health Care Cost Containment System (AHCCCS) program and as defined by AHCCCS for one of the CRS four plan types (see list below). ALL services may be submitted via Phone, Fax or UHC Portal. Instructions for submitting prior authorization requests online can be found at: (CRS) Plan type Definitions: CRS Fully Integrated Group: CRS Partially Integrated Acute Group: CRS Partially Integrated Behavioral Health (BH) Group: CRS Only Group: CRS enrolled members receives CRS, Acute Health Plan benefits and Behavioral Health services, provided by UnitedHealthcare Community Plan (UHCCP) American Indians (AI) receiving all acute health and CRS related services from UHCCP but receiving behavioral health services from a Tribal RBHA (T/RBHA) CMDP and DDD members receiving all behavioral health and CRS related services from UHCCP and receiving acute health services from the Primary program of enrollment Coverage: CRS and BH Conditions Only* (Contact Primary AHCCCS Health Plan for other medical services) Members receiving all CRS related services from UHCCP, receiving acute health services from the Primary program of enrollment, and receiving behavioral health services as follows: 1

2 Services that Require Prior Authorization for CMDP and DDD all member from a Tribal RBHA (T/RBHA) AIHP members from a T/RBHA CRS Only also includes ALTCS/EPD, American Indian Fee for Service members Coverage: CRS Conditions Only* (Contact Primary AHCCCS Health Plan for other medical services) Prior Authorization FAX number: Service Group: #10115 CRS Fully Integrated (Acute-CRS-BH services) Group: #10145 CRS Partially Integrated (Acute-CRS services. AI receiving BH from T/RBHA) Group: #99125 Partially Integrated DDD/CMDP (All CRS & BH services) Group: #99135 CRS Only (DDD/CMDP/AI Enrolled in primary HP and T/RBHA) Behavioral Health Services Acute Inpatient admission Level I Subacute Facility Call: Fax: Refer to T/RBHA Call: Fax: Refer to T/RBHA Residential Treatment Center Level II Short Term (Behavioral Health Residential Facilities) Level III Long Term (Behavioral Health Residential Facilities) Behavioral Health Day Program: Supervised Day Program Therapeutic Day Program Medical Day Program Out of State placements Neuropsychological Testing Respite Services-Non Urgent (Urgent Services No PA needed) 2

3 Services that Require Prior Authorization for Service Group: #10115 / #10145 CRS Fully Integrated & CRS Partially Integrated Acute Group: #99125 / #99135 CRS Partially Integrated Behavioral Health & CRS Only Bone Growth Stimulator Chiropractic Care 1 <21 years old Dental Services Refer to UHC Dental department at CRS Conditions with Dental benefit listed below EPSDT Dental Service: Contact the primary AHCCCS Medicaid Health Plan for dental services Dental CRS benefit conditions: a. Cleft lip and/or cleft palate b. A cerebral spinal fluid diversion shunt where the member is at risk for sub-acute bacterial endocarditis c. A cardiac condition where the member is at risk for sub-acute bacterial endocarditis d. Dental complications arising as a result of treatment for a CRS condition e. Documented significant functional malocclusion Durable Medical Equipment Call Preferred Homecare Eye Care / Optometry 2 For Other Vendors, items >$500 Prior Authorization required call call Nationwide: For Other Vendors, items >$500 Prior Authorization required call Nationwide:

4 Service Services that Require Prior Authorization for Group: #10115 / #10145 CRS Fully Integrated & CRS Partially Integrated Acute Group: #99125 / #99135 CRS Partially Integrated Behavioral Health & CRS Only Genetic Diagnostic Testing 3 Hearing Services Hearing evaluations & hearing aids when completed outside of MSIC No Prior Authorization required for members < 21 years old Home Health Care Services Hospice Services Inpatient Admission 4 (All) Contact Primary AHCCCS Medicaid Health Plan for medical admissions not directly related to the CRS condition Medication Injectables Botox Injections IVIG Infusion Makena Neuropsychological Testing 4

5 Service Services that Require Prior Authorization for Group: #10115 / #10145 CRS Fully Integrated & CRS Partially Integrated Acute Group: #99125 / #99135 CRS Partially Integrated Behavioral Health & CRS Only Out of State Services Outpatient Therapies 5 Occupational Physical Speech Prosthetics 6 and Orthotics 7 Pharmacy Medication not on the Preferred Drug List (ie. the plan Formulary) Pharmacy Hemophilia Factor Drugs: (require PA) Pharmacy Bio Tech Drugs: (require PA) Aldurazyme Ceprotin Cerezyme Elaprase Fabrazyme Lumizyme Myozyme Acthar Gel Kuvan Orfadin Prior Authorization required for items > $ FAX: Specialty Drugs FAX: FAX: FAX: Specialty Drugs FAX: FAX:

6 Service Services that Require Prior Authorization for Group: #10115 / #10145 CRS Fully Integrated & CRS Partially Integrated Acute Group: #99125 / #99135 CRS Partially Integrated Behavioral Health & CRS Only Pregnancy Termination Contact Primary AHCCCS Medicaid Health Plan Podiatry Services 8 Procedures -Capsule endoscopy -Hyperbaric Oxygen Therapy -IM RadiationTherapy -Proton Beam therapy Skilled Nursing Facility Services Sleep Studies (Polysonography testing) Sterilization (male and female) Surgical Interventions and Implants -Bariatric Evaluation/Surgery -Cochlear Implants -Cosmetic & Reconstructive -Joint Replacement -Muscle Flap Procedures -Spinal Cord Stimulator 6

7 Service Services that Require Prior Authorization for Group: #10115 / #10145 CRS Fully Integrated & CRS Partially Integrated Acute Group: #99125 / #99135 CRS Partially Integrated Behavioral Health & CRS Only -Spinal Surgical Procedures -Vagal Nerve Stimulator -Ventricular Assist Device Transplant Services Contact Primary AHCCCS Medicaid Health Plan Transportation 9 (Non-Emergent: Ambulance) Call Prior Authorization Call Prior Authorization Wheel Chair Requests (Power, Manual, Repairs) Wound Vac Treatment Call Prior Authorization Additional Reference Numbers for services Not Requiring Authorization: Home Infusion / Enteral services Call Preferred Homecare Call Preferred Homecare Laboratory Services Refer to Contracted Vendor LabCorp Refer to Contracted Vendor LabCorp Transportation (Non-Emergent: Taxi, Stretcher Van) Call MTBA Call MTBA

8 Footnotes Services that Require Prior Authorization for 1. Chiropractic Not a covered benefit for members > 21 years of age. 2. Eye Care / Optometry Nationwide providers will be in the Find a Doc section: Or Call to Genetic Testing AHCCCS Medical Policy for Genetic Testing Provisions: Prior authorization requests must include documentation regarding how the genetic testing is consistent with the genetic testing coverage limitations. Genetic testing is only covered when the results of such testing are necessary to differentiate between treatment options. Genetic testing is not covered to determine specific diagnoses or syndromes when such diagnoses would not definitively alter the medical treatments of the member. Genetic testing is not covered to determine the likelihood of associated medical conditions occurring in the future. Routine, non-genetic testing for other medical conditions (e.g., renal disease, hepatic disease, etc.) that may be associated with an underlying genetic condition is covered when medically necessary. Genetic testing is not covered as a substitute for ongoing monitoring or testing of potential complications or sequelae of a suspected genetic anomaly. Genetic testing is not a covered service for purposes of determining current or future family planning. Genetic testing is not covered to determine whether a member carries a hereditary predisposition to cancer or other diseases. Genetic testing is also not covered for members diagnosed with cancer to determine whether their particular cancer is due to a hereditary genetic mutation known to increase the risks of developing that cancer. 4. Emergency Services in Hospital / Inpatient Services Emergency services do not require prior authorization. However, hospitals must notify UHC Community Plan if the member is stabilized and admitted to a full Inpatient status. INPATIENT admissions are limited to 25 days per fiscal year for members >21 years old. This does not apply to Medicare QMB enrolled members. Observation services DO NOT require authorization. Observation stay >24 hours will be counted as 1 bed day and will be included in the 25 days per year benefit for > 21 years old. 5. Outpatient Therapy Services OT and ST are not a covered outpatient services for Medicaid members >21 years old. PT has a benefit limit of 15 visits per fiscal year for Medicaid members > 21 years old. This does not apply to Medicare QMB enrolled members. 6. Prosthetics- L5856, L5857, L5858 and L5973 8

9 Services that Require Prior Authorization for Microprocessor controlled lower limbs and microprocessor controlled joints for lower limbs are not a covered benefit. 7. ORTHOTICS - L L4999 AHCCCS considers orthotics to generally be items in codes L0001-L4999 with some exceptions. (There are some supplies which are also listed in this range of orthotic codes. Those supplies are a benefit.) Equipment maintenance and repair of component parts are covered benefit. Documentation that establishes the need to replace a component not operating effectively must be provided at the time prior authorization is sought. (See AHCCCS Policy Manual, Attachment A for listed exceptions) 8. Podiatry Services Services rendered by a Podiatrist or Podiatrist Surgeon are not a covered service for Medicaid members >21 years old. Routine foot care services are a covered service for members > 21 years of age when provided by a primary care physician. 9. Emergency Transportation Emergency transportation does not require prior authorization. Facility to Facility transport via ambulance does not require authorization. Non Emergent Ambulance transportation must meet medical criteria to be a covered benefit. 10. Additional Benefit Exclusions for Members 21 years of age and Older: INSULIN PUMPS E0784 Hardware not covered. Supplies, equipment maintenance and repair of component parts will remain a covered benefit. Documentation that establishes the need to replace a component not operating effectively must be provided at the time prior authorization is sought. PERCUSSIVE VESTS E0483 Supplies, equipment maintenance and repair of component parts will remain a covered benefit. Documentation that establishes the need to replace a component not operating effectively must be provided at the time prior authorization is sought. BONE-ANCHORED HEARING AIDS L8690, L8692 Hardware not covered. Supplies, equipment maintenance and repair of component parts will remain a covered benefit. Documentation that establishes the need to replace a component not operating effectively must be provided at the time prior authorization is sought. COCHLEAR IMPLANTS L8614 9

10 Services that Require Prior Authorization for Hardware not covered. Supplies, equipment maintenance and repair of component parts will remain a covered benefit. Documentation that establishes the need to replace a component not operating effectively must be provided at the time prior authorization is sought. EMERGENCY DENTAL SERVICE Emergency adult dental services eliminated. In accordance with federal law and state plan, AHCCCS will cover medical and surgical services furnished by a dentist only to the extent that such services may be performed under State law either by a physician or by a dentist and such services would be considered a physician service if furnished by a physician. The services must be related to the treatment of a medical condition such as acute pain, infection, or fracture of the jaw. The covered services include examination of the oral cavity, required radiographs, complex oral surgical procedures such as treatment of maxillofacial fractures, administration of an appropriate anesthesia and the prescription of pain medication and antibiotics. Certain pre-transplant services (e.g. dental cleanings, fillings, restorations, extractions) and prophylactic extraction of teeth in preparation for radiation treatment of cancer of the jaw, neck or head are also covered. Other Important Phone Numbers Member Services 8AM 5 PM Provider Services 8AM -5 PM TTY