Prior Authorization Requirements for UHH Group #s 76275 & 76307 (Food Service Plan 376), and UHH Group #s 76305 & 76306 (Food Service Plan 176)
The procedures/services outlined here require prior authorization.
This list was revised on February 10, 2021 and may be subject to change.
- All Inpatient Admissions
- surgical admissions
- medical admissions
- hospice admissions (exclusive of maternity delivery)
- rehabilitation facility admissions (acute rehab, skilled nursing and sub-acute
- mental health and substance abuse admissions (Horizon Behavioral Health 1-800-626-2212)
- Air Ambulance transportation - NON EMERGENT
- Bariatric or Gastric Bypass Procedures -Surgery for Morbid Obesity, including but not limited to Bariatric Procedures, Gastroplasty, Gastric Bypass - outpatient
- Cardiac Radiology Services - Non Emergent Only
Please note that only the following Cardiology Imaging Services require prior authorization by eviCore healthcare for these members- Stress testing (Myocardial perfusion imaging [SPECT and PET], Stress echocardiography)
- Cardiac CT and MRI
- Echocardiography: transthoracic and transesophageal
- Diagnostic heart catheterization
- Clinical Trials
- Cosmetic procedures and potentially cosmetic procedures including but not limited to cosmetic dermatology services; varicose vein procedures
- Durable Medical Equipment (DME) - Certain DME items costing over $500
Visit the Horizon Care@Home webpage or call CareCentrix at 1-855-243-3321. - Gender Reassignment
- Habilitative therapy for children with autism spectrum disorder (ABA therapy).
Please call Call HealthCheck360 at 1-844-462-7812 for services to be provided after January 31, 2021. - Home Health Care Services – all skilled services in the home
- Home Hospice Services
- Home Infusion Services
Visit the Horizon Care@Home webpage or call CareCentrix at 1-855-243-3321. - Hyberbaric oxygen therapy
- Medical Foods
- Mental health and Substance Abuse Services (Horizon Behavioral Health 1-800-626-2212)
- Inpatient (IP)
- Inpatient Detox
- Residential (RTC)
- 23hr bed
- 72hr bed
- Partial Hospitalization (PHP)
- Intensive Outpatient (IOP)
- Psychological Testing
- In Home Services
- Electroconvulsive Therapy (ECT)
- Transcranial Magnetic Stimulation (TMS)
- Molecular and Genomic Testing services
Visit the Molecular and Genomic Testing Program webpage or call eviCore healthcare at 1-866-496-6200. - Prosthetics/Orthotics - over $500
Visit the Horizon Care@Home webpage or call CareCentrix at 1-855-243-3321. - Radiation Therapy services
Visit the Radiation Therapy Program webpage or call eviCore healthcare at 1-844-224-0493. - Radiology/Imaging Services including but not necessarily limited to:
- Magnetic Resonance Imaging (MRI)
- Magnetic Resonance Angiograms (MRAs)
- Positron Emission Tomography (PET) scans
- Positron Emission Tomography – Computed Tomography (PET-CT)
- Computerized Tomography (CT) scans
- Computed Tomography Angiography (CTA) scans
- Nuclear Medicine
- Nuclear Cardiac Imaging
- Specialty Pharmaceuticals/Medical Injectable Drugs (e.g. Botox, IVIG, Flolan and derivates; Xolair)
Visit the Medical Injectables Program webpage or call Magellan Rx Management at 1-800-424-4508. - Transplant Services except Corneal Transplants (Case Management)
- Travel and Lodging benefits Call UNITE HERE HEALTH at 1-833-637-3519.
