OMNIA Health Plans

SERVICES REQUIRING PRIOR AUTHORIZATION

The following services/supplies require prior authorization:

• Ambulance Air
• Artificial Insemination
• Complex Diagnostic X-Ray CAT Scan/MRI/MRA/ MRS/Pet Scan/Nuclear testing
• Cosmetic/Reconstructive Surgery
• Durable Medical Equipment
• Electroshock Therapy
• Facility-Inpatient
• Home Health Care
• Home Infusion Therapy
• Hospice
• Infertility Services
• Organ Transplant
• Private Duty Nursing
• Skilled Nursing Facility

The following require prior authorization only when rendered on an inpatient basis:

• Chemotherapy
• Cognitive Rehabilitation
• Dialysis Services (includes hemodialysis and peritoneal dialysis)
• Infusion Therapy
• Mental Health Care
• Occupational Therapy
• Physical Therapy
• Radiation Therapy
• Recreational Therapy
• Speech Therapy
• Substance Abuse
• TMJ Treatment (Surgical and Non-Surgical)