Lynne A. Valenti
Cabinet Secretary

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Prior Authorization

Listed below are all services requiring prior authorization and the associated Prior Authorization Request Form. Prior Authorization criteria and detailed instructions regarding forms and submission of prior authorization requests are located in the Prior Authorization Manual.

Out-of-State Services

  • Inpatient Services
  • Outpatient Services

Out-of-State Prior Authorization Request Form
Out-of-State FAQ

Durable Medical Equipment

  • Bone Growth Stimulators
  • Continuous Glucose Monitoring Policy
  • Continuous Passive Motion Devices
  • Cough Stimulating Devices
  • Cranial Remolding Helmets
  • High-Frequency Chest Wall Oscillation Device
  • Low Air Loss Mattress / Pressure Reduction Therapy
  • Lymphedema pumps
  • Non-covered items < age 21 (EPSDT)
  • Speech Generating Devices / Augmentative Communication Devices
  • Wound Vacs

DME and Nutrition Prior Authorization Request Form

Home Health

  • Extended Home Health Services / Private Duty Nursing

Private Duty Nursing & Extended Home Health Services Prior Authorization Request Form

Inpatient Hospitalization

  • Long Term Acute Care
  • Medically Complex / Rehab < age 21
  • Neonatal Intensive Care Units
  • NICU transfers Out Of State
  • Psychiatric Residential Treatment Facilities
  • Psychiatric Units
  • Rehabilitation Units

General Prior Authorization Request Form

Nutrition

  • Enteral Nutrition for > age 21
  • EPSDT special requests < age 21
  • Parenteral

DME and Nutrition Prior Authorization Request Form

Other Outpatient Services

  • Botox
  • Hyperbaric Oxygen Treatment
  • Makena
  • Mental Health visits < age 2
  • Mental Health visits over coverage limit
  • Non-covered services < age 21 EPSDT (Vision, audiology, etc.)

General Prior Authorization Request Form

  • Synagis

Synagis Prior Authorization Form

Surgical Procedures

  • Bariatric
  • Breast Reconstruction
  • Breast Reduction
  • Cochlear implants
  • Nerve stimulators
  • Panniculectomy
  • Questionably cosmetic
  • Removal of excess skin
  • Spinal
  • Transplants

General Prior Authorization Request Form

Other Procedures

These procedures do not require prior authorization, but they do have specific requirements including a specialized form.

  • Hysterectomy

Hysterectomy Acknowledgement of Information

  • Sterilization

Sterilization Consent Form