The following services require prior authorization.
- All inpatient admissions, including planned surgical procedures
- All outpatient surgical procedures, including amputations
- Allergy testing
- Ambulance services, nonemergency
- Chemotherapy (requests for injections related to chemotherapy should be submitted to the Optum® Cancer Guidance Program through MBMNow; see section B.8 (Medical Management Programs)
- Cosmetic and experimental procedures
- Diagnostic and exploratory procedures
- Durable medical equipment, including but not limited to lancets and test strips
- Enhanced external counterpulsation
- Fertility procedures
- Genetic testing
- Home health
- Injections, including BOTOX, SYNVISC and similar injections for osteoarthritis or spider vein, epidural steroid, and all injections related to chemotherapy and dialysis
- Laser treatment to the eyes for elective procedures
- Mental health care and substance abuse services
- Myocardial perfusion tests beyond coverage guidelines (once every 12 months)
- Outpatient therapies
- Preventive services provided beyond coverage guidelines (reference the form for guidelines)
- Select Medicare Part B-covered drugs
- Sleep studies
- Transplant evaluations and all related treatment
- Vascular procedures
- Unlisted codes, drugs and procedures
- Wound care treatment
Note: You must obtain prior authorization from Peoples Health before administering any medical services, excluding an initial medical history and physical, to a Peoples Health patient while the patient is at an inpatient facility for behavioral health services. If authorization is not obtained, any claims for these services will be denied, and you will be responsible for the total costs. Authorization will not be granted retroactively for services that have already been administered.
Please remember, claims for any visits with or services provided to Peoples Health patients in an inpatient behavioral health setting should be submitted to Peoples Health for payment, excluding claims for the patient’s initial medical history and physical. As an additional reminder, only the servicing provider indicated on the authorization request may provide authorized medical services to the patient.