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PRIOR AUTHORIZATION - GENERAL RULES
The following table outlines the general Bravo Health prior authorization and care direction procedures:
Ambulance (Place of Service 41)
No Authorization Required for "911" ambulance service
Only Medicare covered ambulance services. Routine Ambulance NOT COVERED
Behavioral Health Inpatient & Outpatient
Pennsylvania & Mid-Atlantic
Contact CompCare : 1-800-541-3647
Texas
Contact Corphealth : 1-866-671-4537
Chiropractic
The only codes covered to chiropractic care are: 98940, 98941, 98942, 98943
Clinical Trials
Must Notify Plan (Original Medicare Plan pays for clinical trials with 20% coinsurance to the
Member)
Dental
Pennsylvania & Mid-Atlantic
Contact Doral Dental : 1-800-341-8478
Texas
Contact StarDent : 1-866-753-6319
Laboratory
Lab services provided by any lab other than those listed below require pre-authorization except for
certain procedures that can be performed in outpatient settings. See appropriate place of service guide
for a list of codes.
Philadelphia & Mid-Atlantic
MUST use Quest Labs
Pittsburgh
Can use participating hospitals and Quest Labs
Texas
Can use Clinical Pathology Lab (CPL) or Quest Labs
Lab services performed at skilled nursing and long term care facilities do not require pre-
authorization.
Non-Participating Providers
NON PARTICIPATING
PROVIDERS
(All non-Participating providers require prior authorization
except Chiropractor, Radiologist and Anesthesiologist, or ER)
Podiatry
Routine
Refer to specific plan benefits
Non-Routine
Refer to Medicare Coverage Guidelines
Professional Services
Modifier 26 professional component does not require an authorization for Participating or Non
Participating Providers.
