Services Requiring Prior Authorization - NBHD/MHS/PHT
SFCCN PSN Services Requiring Prior Authorization*:
- Chemotherapy
- Consults-Outpatient:
- All out of Subnetwork
- All out of SFCCN network referrals
- Specialist to specialist referrals
- Dental Services specific to Orthodontics, Dentures and Appliances (MHS & NBHD only)
- Dialysis (peritoneal & hemodialysis)
- Elective Surgery (Inpatient, Outpatient & Ambulatory Surgery)
- Emergency Visits (authorization is for payment only, not service approval)
- Enteric Feedings/Nutritional Supplements
- All Invasive Diagnostic procedures to include but not be limited to endoscopies, cardiac catheterizations, electrophysiologic studies (EPS), angiograms, cystograms, and amniocentesis
- Growth Hormone Treatment
- Home Health Care/DME/Oxygen & Related Equipment and Services
- Hyperbaric Oxygen Therapy
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- Inpatient Admissions (Emergency and Non-Emergency)
- Mental Health Inpatient Admissions (UMBH: 800-294-8642)
- MRI
- Observational Stays
- Obstetrical Care (Block Authorization)
- Oral Surgery
- Orthotics/Prosthetics
- PET Scans
- Pharmacologic/Exercise/Echo Stress Tests (Thallium, Cardiolyte, etc.)
- Plastic Surgery
- Radiation Therapy
- Sleep Apnea Studies and Related Care
- Therapy Services – Speech/Occupational/Physical Therapies
- Transplants and Related Care
- Any service authorizations/pending cases prescribed or authorized before the enrollee's effective date with the PSN
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* InterQual and national guidelines criteria and Medicaid Coverage and Limitations Handbooks will be used to evaluate requests for medical appropriateness/necessity.
Contact
SFCCN Utilization/Authorization
PHT — 305-575-3700
MHS — 954-276-3131
NBHD — 954-767-5640
