What is Prior Authorization?
Some medical services, surgical procedures, and medications require IHN-CCO’s written approval before you can get them. This process is called Prior Authorization. It basically means that your provider has to ask permission to prescribe you a drug or have you undergo a treatment, service, or surgery that isn’t covered by your health plan.
How does it work?
Your provider fills out a form requesting permission to give you a certain drug, treatment, service, or surgery. If approved, it will be covered to some extent by IHN-CCO. If not, IHN may recommend an alternative that is covered, or you may opt to get the drug, treatment, service, or surgery anyway and cover the costs yourself.
What requires authorization?
IHN-CCO reviews and updates its Prior Authorization lists annually. For 2018, IHN-CCO requires Prior Authorization for the following:
Medical services & surgical procedures
Acupuncture
All non-contracted services. Exceptions: labs, x-rays, and dialysis
Chemical Dependency: Inpatient and Residential; Medical/Chemical Detoxification
Contact Lenses
Durable Medical Equipment (DME) over $150: Prosthetics, Orthotics, and Hearing Aids; Cochlear implants, replacements and repairs; Continuous Glucose Monitors (CGM) and CGM Supplies. Exceptions: Incontinence, diabetic, CPAP and Cast supplies
Elective/Planned procedures in the Hospital or Ambulatory Surgery Center includes the following: Genetic testing, except standard prenatal testing and Non-Invasive Prenatal Testing (NIPT); Neck and back surgery (done as inpatient, outpatient and those done as in-office procedures). Exception: Colonoscopies and Endoscopies
Inpatient Hospital Care, including Inpatient Rehabilitation. Exception: Labor & delivery; Exception: Newborn less than 5 days; Exception: Respiratory/pulmonary therapies
Mental Health Services: Day Treatment; Inpatient and Residential
Outpatient Rehabilitation services in excess of 30 visits (120 units) per calendar year, including: Occupational Therapy, Physical Therapy, Speech Language Therapy
Potentially cosmetic, reconstructive and/or experimental surgery and services (including Botox Injections)
Radiological services (for the following): Thorax CT Scan (CPT 71250) and LDCT for lung cancer screening (HCPC G0297); Magnetic Resonance Imaging (MRI); Nuclear Medicine – PET and CTA coronary
Skilled Nursing Facility (SNF)
Transplants (including evaluation): Corneal and Kidney transplants only require approval if performed out of state
InterCommunity Health Network CCO has the right to review or otherwise deny services that are not found to be medically appropriate.
*Diabetic supplies that DO require approval: Insulin pumps, diabetic shoes/inserts.
*Diabetic supplies that DO NOT require approval: lancets, test strips, meters, syringes, and pump supplies.
Medically appropriate - Services and medical supplies that are required for prevention, diagnosis or treatment of a health condition which encompasses physical or mental conditions, or injuries, and which are:
Consistent with the symptoms of a health condition or treatment of a health condition;
Appropriate with regard to standards of good health practice and generally recognized by the relevant scientific community, evidence-based medicine and professional standards of care as effective;
Not solely for the convenience of the member or a provider of the service or medical supplies; and
The most cost effective of the alternative levels of medical services or medical supplies that can be safely provided to the member.
Emergency services do not require prior approval. We do request notification of all emergency inpatient admissions.
Some of your prescription drugs may require prior authorization. To find out if your medication requires prior authorization, please search our Formulary.
