Lynne A. Valenti
Cabinet Secretary

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Prior Authorization

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.

Out-of-State Services

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.  

  • Inpatient Services
  • Outpatient Services

Out-of-State Prior Authorization Request Form

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.

Durable Medical Equipment

  • Bone Growth Stimulators
  • Continuous Glucose Monitoring
  • 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

  • BRCA

BRCA Prior Authorization 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

 

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