Prior Authorization Notification And Referral Guidelines-PDF Free Download

Prior Authorization Notification and Referral Guidelines
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Medical Policy Notes, Service Authorization, Abortion No Abortions for pregnancies beyond twenty three. weeks and 6 days are not allowed in Massachusetts, unless performed to save the life of the mother or to. eliminate substantial risk of grave impairment to, her physical or mental health. Elective inpatient admissions require prior, authorization Emergency admissions require. notification, Acupuncture For the No Please refer to plan materials for office visit limits.
Treatment of, Pain My Care Family MVACO see Medical Policy. Acupuncture, Ambulance Emergency No See Medical Policy. Transportation Non emergency Medically Necessary, including Transportation. Inter facility, Specialty Care, Non emergent Yes Covered when criteria are met Refer to the. Transportation medical policy FOR COMMERCIAL MEMBERS. See Medical Policy, Non emergency Medically Necessary.
Transportation, My Care Family MVACO Non emergent, ambulance transporting is covered through. MassHealth, AllWays Health Partners includes AllWays Health Partners Inc and AllWays Health Partners Insurance Company. Medical Policy Notes, Service Authorization, Ambulatory Surgical Procedure Yes Not all Ambulatory Surgical Procedures require. prior authorization Please refer to Surgical Day, Prior authorization must be obtained at least five. 5 business days prior to an elective procedure date. and may take up to 14 calendar days to complete, Ambulatory Surgical Services include up to 8 hours.
of observation recovery services A separate, notification authorization number for the. observation recovery services up to the initial 8, hours is not required When the. observation recovery services exceed the initial 8. hours a separate and new notification authorization. is required, When the observation recovery services exceed the. 8 hour period a separate notification is required, See Observation. Artificial Pancreas Device System Yes See Medical Policy. Artificial Pancreas Device System, Autologous Chondrocyte Yes See Medical Policy.
Implantation in the Knee Autologous Chondrocyte Implantation in the Knee. Bariatric Surgery Yes See Medical Policy, Weight Loss Surgery Bariatric Surgery. Bed Hold 20 Day Yes Covered only for My Care Family MVACO plans. with a Skilled Nursing Facility benefit, See Medical Policy. Extended Care Facility, Blepharoplasty Yes See Medical Policy. Reconstructive and Cosmetic Procedures, AllWays Health Partners includes AllWays Health Partners Inc and AllWays Health Partners Insurance Company. Medical Policy Notes, Service Authorization, Bone Growth Stimulation Yes Ultrasound noninvasive and invasive electric.
bone growth stimulation, See Medical Policy, Bone Growth Stimulators. Breast Implant Removal Yes See Medical Policy, Breast Surgeries. Reconstructive and Cosmetic Procedures, Breast Reduction for Yes See Medical Policies. Gynecomastia Breast Surgeries, Reconstructive and Cosmetic Procedures. Breast Revision Augmentation Yes See Medical Policies. Surgery Breast Surgeries, Gender Affirming Procedures.
Reconstructive and Cosmetic Procedures, Cardiac Imaging Yes Prior authorization is required for outpatient. non emergent diagnostic advanced imaging, See AllWays Health Partners s eviCore resource. page on AllWays Health Partners org for CPT, codes subject to prior authorization and Clinical. Guidelines, eviCore Resource Page CPT codes and Clinical. Guidelines, Cardiac Cardiac Yes See Medical Policy for services that require a PA.
Outpatient Outpatient Mobile, Mobile Cardiac Outpatient Telemetry. Monitoring Telemetry, Holter Monitoring No, Event Monitoring No. AllWays Health Partners includes AllWays Health Partners Inc and AllWays Health Partners Insurance Company. Medical Policy Notes, Service Authorization, Chiropractic My Care Family No My Care Family MVACO No prior. Services Visits MVACO authorization is required for the 20 visits per benefit. Benefit period is October 1 September 30, Commercial Please refer to plan materials for. PA requirements and benefit limit, See Medical Policy.
Chiropractic Services, Commercial Yes, Cleft Lip and 17 yrs of age and Yes Not covered. Palate Repair under See Medical Policies, 18 yrs of age and Yes Oral and Maxillofacial Surgery and Procedures. older Dental Treatment Setting, Clinical Trials No See Medical Policy. Experimental and Investigational, Cochlear Implants and Bone Yes See Medical Policy. Anchored Hearing Aids, Hearing Devices, Continuous Glucose Monitoring Yes See Medical Policy.
Continuous Glucose Monitors, Corneal Transplants Yes. AllWays Health Partners includes AllWays Health Partners Inc and AllWays Health Partners Insurance Company. Medical Policy Notes, Service Authorization, Cosmetic Reconstructive Yes Includes but not limited to. Blepharoplasty, Surgery Breast Implant Removal, Mastectomy for Gynecomastia. Chest Deformities, Dermabrasion, Oral Maxillofacial Surgery incl cleft lip and. palate repair, Rhinoplasty, Septoplasty, Scar Revisions.
Varicose Vein Treatment, See Medical Policy, Reconstructive and Cosmetic Procedures. Breast Surgeries, Dental Treatment Setting Yes See Medical Policy. Dental Treatment Setting, Inpatient Surgical Day, Also reference. Oral and Maxillofacial Surgery and Procedures, Dermabrasion Yes See Medical Policy. Reconstructive and Cosmetic Procedures, Destruction of vascular Yes See Medical Policy.
Cutaneous Lesions, Reconstructive and Cosmetic Procedures. Diabetic Insulin Pump and NO See Medical Policies, Supplies Pump Supplies Insulin Pumps. DME Medical policy will be updated 11 25 19 to reflect. no PA required, AllWays Health Partners includes AllWays Health Partners Inc and AllWays Health Partners Insurance Company. Medical Policy Notes, Service Authorization, Continuous Yes. Glucose Monitors AllWays Health Partners members with a. pharmacy benefit can obtain lancets test strips, insulin alcohol pads syringes etc from.
participating pharmacies For members with no, pharmacy coverage through AllWays Health. Diabetic Supplies No Partners diabetic supplies may be covered under. their pharmacy through their employer, Continuous Glucose Monitors. Durable Medical Equipment Yes Not all DME requires authorization Prior. DME authorization depends upon the type of DME, Please reference the DME Prior Authorization list. for DME that requires authorization, Prior Authorization Guidelines for AllWays Health. Partners plans and members, The ordering clinicians can contact vendors directly.
to place the orders In turn vendors will contact, AllWays Health Partners DME department to. initiate the authorization process, Early Screening No Restricted to members under the age of 3. Intervention assessment and, treatment for, children with. developmental, delays and, disabilities, AllWays Health Partners includes AllWays Health Partners Inc and AllWays Health Partners Insurance Company. Medical Policy Notes, Service Authorization, Early Early Yes Commercial.
Intervention Intervention, For members receiving Early Intervention services. who may qualify for ABA, Behavioral, Analysis Under the age of 3 Applied Behavioral Analysis. ABA services are reviewed by AllWays Health, Partners in coordination with our behavioral health. Over the age of 3 Applied Behavioral Analysis, ABA services are reviewed by our behavioral. health partner Please submit request directly to, My Care Family MVACO.
Under the age of 3 Applied Behavioral Analysis, ABA services are reviewed by MassHealth. Please submit request directly to MassHealth, Over the age of 3 Applied Behavioral Analysis. ABA services are reviewed by Optum Please, submit request directly to Optum. Elective Inpatient Surgery Yes Prior authorization required at least five 5. business days prior to the surgery date, Authorization may take up to 14 calendar days to. Also see Inpatient Admissions, Enteral Parenteral and Yes No PA required for food thickeners.
Nutritional Formulas, AllWays Health Partners includes AllWays Health Partners Inc and AllWays Health Partners Insurance Company. Medical Policy Notes, Service Authorization, Eye Related Cosmetic Surgery Yes Such as but not limited to. Radial Keratotomy, Blepharoplasty, Repair of Blepharoptosis. Brow Ptosis, Excision Repair or Reconstruction of the. See Medical Policy, Reconstructive and Cosmetic Procedures.
Facial Surgery and Prosthetics Yes See Medical Policy. Reconstructive and Cosmetic Procedures, Gender Affirming Procedures Yes See Medical Policy. Gender Affirming Procedures, Genetic Molecular Genomic Yes Prior authorization is required for outpatient. Testing non emergent Molecular Genomic Testing, Prior authorization is not required for Molecular. Genomic Testing performed during an inpatient, See AllWays Health Partners s eviCore resource. page on AllWays Health Partners org for CPT, codes subject to prior authorization and Clinical.
Guidelines, Genital Surgery Yes As part of treatment for gender dysphoria. See Medical Policy, Gender Affirmation Procedures, AllWays Health Partners includes AllWays Health Partners Inc and AllWays Health Partners Insurance Company. Medical Policy Notes, Service Authorization, Hearing Hearing Aids Yes Commercial coverage is generally based on. MGL Chapter 233 of the Acts of 2012 an act, providing hearing aids for children Some plans. may have coverage for member 22 years of age and, older Consult the member s summary of benefits.
Cochlear Yes See Medical Policy, Implants Bone Hearing Devices. Hearing Aids, Bone Anchored, Hearing Devices, HIV associated Lipodystrophy Yes See Medical Policy. HIV associated lipodystrophy syndrome, Home Health Home Health Yes See Medical Policy. Services Aid, Home Health Care, Home Medical Yes See Medical Policy. Social Worker, Home Health Care, Home Yes See Medical Policy.
Nutritional, Counseling Home Health Care, AllWays Health Partners includes AllWays Health Partners Inc and AllWays Health Partners Insurance Company. Medical Policy Notes, Service Authorization, Home Skilled Yes Two post partum home visits do not require prior. Nursing authorization Skilled nursing visits initiated on. non business days such as over a weekend or, holiday require notification on the next business. day Subsequent visits do require prior, authorization. My Care Family MVACO The initial, evaluation and re evaluation do not require prior.
authorization Subsequent visits do require prior, authorization. See Medical Policy, Home Health Care, Home Yes Commercial no prior authorization is required for. Occupational OT PT ST, See Medical Policy, Home Physical Yes. Home Health Care, Home Speech Yes, Therapy My Care Family MVACO The initial. evaluation and re evaluation do not require prior, authorization Subsequent visits do require prior.
authorization, Medication Yes This service is only covered for My Care Family. Administration MVACO, Please note this is not Medication Assisted. Treatment MAT for substance use, See Medical Policy. Home Health Care, AllWays Health Partners includes AllWays Health Partners Inc and AllWays Health Partners Insurance Company. Medical Policy Notes, Service Authorization, Hospice Hospice No.
inpatient and, outpatient care, Hospice Respite No. Infertility Services Assisted Yes My Care Family MVACO coverage limited to. Reproductive Technology diagnosis of infertility and treatment of underlying. Artificial Insemination Intra medical condition Assistive reproductive services. uterine Insemination Fertility are not a covered benefit. Commercial Some employer groups may exclude, coverage for assisted reproduction Refer to plan. See Medical Policy, Infertility Services, Infusion Ther Clinic Office No Some specialty pharmacy drugs require Prior. Infusion Authorization regardless of setting office or. Therapy Home Yes home, Please reference Medical Specialty Drugs. Inpatient Elective Yes Elective inpatient admissions require PA Prior. Admissions authorization must be obtained at least five 5. business days prior to an elective procedure date, and may take up to 14 calendar days to complete.
Emergency non No Emergency only notification is required within. elective 24 hours or by the next business day to, Emergency Maternity Please refer to Inpatient. Sick Newborn Yes Commercial Newborn must be enrolled in the. plan for coverage to apply notification is required. within 72 hours or by the next business day, AllWays Health Partners includes AllWays Health Partners Inc and AllWays Health Partners Insurance Company. Medical Policy Notes, Service Authorization, Inpatient Preterm Yes Preterm antepartum admissions require prior. Maternity Antepartum authorization regardless of delivery. Includes emergency maternity admissions, Delivery No If the member delivers while inpatient for pre. term antepartum admission then no, notification auth is required for the delivery.
Postpartum Yes, Institutional Extended Care Yes This includes. Skilled Nursing Facility, Acute Rehabilitation Hospital. Long Term Care Hospital LTCH Chronic, Disease Hospital level of care. Prior Authorization Notification and Referral Guidelines The chart below is an overview of customary services that require referral prior authorization or notification for all Plans Please note PPO and EPO members can see specialists without obtaining a referral from AllWays Health Partners Referral Guidelines vary by plan please refer

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