The division has 30 days to make a prior authorization determination. However, in most circumstances authorizations can be completed in less time, usually around 2 weeks. Prior authorization is only required for the elective services listed on this webpage. Any urgent or emergent care is exempt from prior authorization requirements. Retro authorizations can be requested after the service is provided if care was suspected to be urgent/emergent at the time, but will be billed as elective.
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.
Requests for elective out of state services should be generated by the referring in state physician/specialist at the time of that referral. Medical records form the visit that prompted the referral should accompany the prior authorization request form. Requests from the out of state provider will also be accepted. However, this is only preferred when a recipient’s care has already been established there. Requests from out of state providers should be accompanied by records of their most recent services there. Authorization requests should also include a schedule of planned care throughout the next year if more than one service is anticipated. This will decrease the number and frequency of authorizations needed.
Not all services provided out-of-state require a prior authorization. Please review the Out-of-State FAQ for more information on services requiring a Prior Authorization and other questions.
These procedures do not require prior authorization, but they do have specific requirements including a specialized form.
Current Procedural Terminology (CPT) codes, descriptions and other data only are copyright 2015 American Medical Association (AMA).
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