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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 August 31, 2020 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
    Visit the Cardiology Imaging Program webpage or call eviCore healthcare at 1-866-496-6200.
  • 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 Medical Cost Management Corporation at 1-800-367-9938.
  • 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
    Visit the Radiology/Imaging Services webpage or call eviCore healthcare at 1-866-496-6200.
  • 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.