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Services Requiring Prior Authorization

Prior authorization is not a guarantee of payment for the service(s) authorized. Keystone First reserves the right to adjust any payment made following a review of the medical record and determination of medical necessity of the services provided.

Members with Medicare coverage may go to Medicare Health Care Providers of choice for Medicare covered services, whether or not the Medicare Health Care Provider has complied with Keystone First’s Prior Authorization requirements. Keystone First’s policies and procedures must be followed for Non-Covered Medicare services.

The following is a list of services requiring prior authorization review for medical necessity and place of service.

  1. All elective (scheduled) inpatient hospital admissions, medical and surgical including rehabilitation
  2. All elective transplant evaluations and procedures
  3. Elective/non-emergent Air Ambulance Transportation
  4. All elective transfers for inpatient and/or outpatient services between acute care facilities
  5. Skilled Nursing facility admission for alternate levels of care in a facility, either free-standing or part of a hospital, that accepts patients in need of skilled level rehabilitation and/or medical care that is of lesser intensity than that received in a hospital, not to include long term care placements
  6. Gastroenterology services (codes 91110 and 91111 only)
  7. Bariatric surgery
  8. Pain management services performed in a short procedure unit (SPU) or ambulatory surgery unit (either hospital-based or free-standing) and pain management services not on the Medical Assistance fee schedule performed in a physician’s office.
  9. Cosmetic procedures, regardless of treatment setting, to include, but not limited to the following: reduction mammoplasty, gastroplasty, ligation and stripping of veins, and rhinoplasty
  10. Outpatient Therapy Services (physical, occupational, speech)
    • Prior authorization is not required for an evaluation andup to 24 visits per discipline within a calendar year
    • Prior authorization is required for services exceeding 24 visits per discipline within a calendar year
  11. Cardiac and Pulmonary Rehabilitation
  12. Chiropractic services after the initial visit
  13. Home Health Services by a network provider
    • Prior authorization is not required for up to 6 home visits per modality per calendar year including: skilled nursing visits by a RN or LPN; Home Health Aide visits; Physical Therapy; Occupational Therapy and Speech Therapy
    • The duration of services may not exceed a 60 day period. The member must be re-evaluated every 60 days
    • All Shiftcare/Private Duty Nursing services, including services performed at a medical daycare or Prescribed Pediatric Extended Care Center (PPECC)
    • Injectables
    • Home Sleep Study
  14. DME
    • Purchase of all items in excess of $750
    • DME monthly rental items regardless of the per month cost/charge
    • The purchase of all wheelchairs (motorized and manual) and all wheelchair items (components) regardless of cost per item
    • The rental of all wheelchairs (motorized and manual) and all wheelchair items (components) regardless of cost per item
    Enterals:
    • Prior authorization is required for members over the age of 21
    • Prior authorization is required when the request is in excess of $350/month for members under the age of 21
    Diapers/Pull-ups:
    • Any request in excess of 300 a month for diapers or pull-ups or a combination of both.
    • Requests for brand specific diapers.
    • All requests for diapers supplied by a DME provider, other than J&B Medical Supply, Bright Medical Supply, King of Prussia Pharmacy, or Matts Pharmacy & Medical Supply (refer to the Durable Medical Equipment page 37 of provider manual for complete details)
  15. Any service(s) performed by non-participating or non-contracted practitioners or providers, unless the service is an emergency service
  16. All services that may be considered experimental and/or investigational
  17. Neurological Psychological Testing
  18. Genetic Laboratory Testing
  19. All miscellaneous/unlisted or not otherwise specified codes
  20. Any service/product not listed on the Medical Assistance Fee Schedule or services or equipment in excess of limitations set forth by the Department of Human Services fee schedule, benefit limits and regulation. (Regardless of cost, i.e. above or below the $500 DME threshold)
  21. Ambulance Transportation to and from Prescribed Pediatric Extended Care Center PPECC/Medical Daycare Guidelines:
    • Member under 21 years of age
    • Member approved for services at a PPECC/Medical Daycare
    • Member requires intermittent or continuous oxygen, ventilator support and/or critical physiologic monitoring or critical medication(s) during transport requiring ambulance level of care
    • There are no existing mechanisms for caregivers to transport the member
    • Request for ambulance services are prior authorized along with initial request for PPECC/Medical Daycare services, with each re-authorization of Medical Daycare services, and/or when there is a change in level of care regarding oxygen, ventilator support and/or specific medical treatment during transport
      Member Services Transportation Department will be notified with each ambulance approval to initiate and/or continue ambulance transport services
  22. Radiology - The following services, when performed as an outpatient service, requires prior authorization by Keystone First’s radiology benefits vendor. Refer to the Radiology Services section of provider manual for details.
    • Positron Emission Tomography (PET)
    • Magnetic Resonance Imaging (MRI)/Magnetic Resonance Angiography (MRA)
    • Nuclear Cardiology/MPI
    • Computed Axial Tomography (CT/CTA/CCTA)
  23. Select prescription medications. For information on which prescription drugs require authorization, visit the Pharmacy Prior Authorization page.
  24. Select dental services. For information on which dental services require authorization, please refer to the Dental Services section of provider manual.
  25. Elective termination of pregnancy – Refer to the Termination of Pregnancy section of provider manual for complete details.

*Prior authorization is not a guarantee of payment for the service(s) authorized. Keystone First reserves the right to adjust any payment made following a review of the medical record and determination of medical necessity of the services provided.

Emergency room, Observation Care and inpatient imaging procedures do not require Prior Authorization.

Members with Medicare coverage may go to Medicare Health Care Providers of choice for Medicare covered services, whether or not the Medicare Health Care Provider has complied with Keystone First’s Prior Authorization requirements. Keystone First’s policies and procedures must be followed for Non-Covered Medicare services.