Services Requiring Prior Authorization - CMS 19/CMS 21
CMSN Services Requiring Prior Authorization*:
- Chemotherapy
- CT Scan
- Dental Services for Orthodontics, Appliance and Dentures **
- Durable Medical Equipment (DME) – ALL, including but not limited to:
- Oxygen and related equipment/services
- Custom Wheelchair
- Orthotics, Prosthetics and/or Braces
- Insulin Pump
- Elective Surgery (inpatient or outpatient)
- Emergency Room Visits (notification is required for payment processing only)
- Growth Hormone
- Hearing Aids
- Home Health
- Hyperbaric Oxygen Therapy
- Inpatient Admissions
- Invasive Diagnostic Procedures – ALL, including but not limited to:
- Amniocentesis
- Angiograms, Angioplasty
- Cardiac Catheterizations
- Cystograms
- Electrophysiological Studies (EPS)
- Endoscopies
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- Magnetic Resonance Imaging (MRI)
- Mental Health Inpatient Admissions (UMBH: 800-294-8642)
- Nutritional Supplements
- Observational Stays
- Obstetrical Care (Global)
- Out-of-Network Services (OON), including referrals and/or consultations
- Oral Surgery (Medical)
- PET Scan
- Prescribed Pediatric Extended Care Services (PPEC)
- Radiation Therapy
- Sleep Apnea Studies
- Specialist to Specialist Referrals
- Stress Tests (Pharmacologic, exercise, Stress, Thallium, Cardiolyte, etc.)
- Therapies – Occupational / Physical / Respiratory / Speech
- Transplants and Related Care
- Video EEG
- Video Esophageogram
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* InterQual and national guideline criteria and Medicaid Coverage and Limitations Handbooks will be used to evaluate requests for medical appropriateness/necessity.
** Only CMSN Medicaid – Dental Services are received directly through CMS for Florida KidCare
Contact
CMSN-S FL Region Florida KidCare (Miami-Dade and Monroe)
Utilization/Authorization
PHT — 1-800-721-2993
CMSN-Broward Medicaid Utilization/Authorization
NBHD — 1-800-988-5640
MHS — 1-866-209-5022
CMSN-SE FL Region Florida KidCare Utilization/Authorization
NBHD — 1-800-988-5640
(North Broward, Martin, St. Lucie, Indian River & Okeechobee)
MHS — 1-866-202-1132
(South Broward & Palm Beach)
