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Acute Hospital Admissions (All)
Acute Rehab Admissions (All)
Behavioral Health Hospital Admissions (CompCare or
Corphealth) *See Behavioral Health
Elective Admissions (All)
Long Term Acute Care Hospital Admissions (LTACH)
(All)
Skilled Nursing Admissions (All)
INPATIENT SERVICES
Sub acute Admission (All)
RADIATION THERAPY
Intensity-Modulated Radiation Therapy (IMRT) - Prior
authorization is required only for elective admission. A
course of therapy occurring as part of an inpatient
confinement that has met medical necessity criteria and
been authorized does not require separate authorization.
Emergency Room/Urgent Care (Place of Service 20&23)
No Authorizations are required
Outpatient Hospital (Place of Service 22)
Diabetic Education Training (Except Senior Partners)
Dialysis Self Training
EDUCATION
Nutritional Education Classes (97802-97804) Diabetes
and Renal
LABORATORY
Labs (ALL) except these labs that may be performed in
Physician's Office: 85018, 82947, 82962, 81000, 81002,
81003, 81005, 86308, 86403-86406
Infusion Therapy (except exclusion list) *see pages 43-44 MEDICATIONS AND INJECTIBLES
Injectibles (except Influenza, Pneumococcal, Tetanus and
Hepatitis B) *see attachment
IMMUNIZATIONS (except
Influenza, Tetanus, Hepatitis B and
Pneumovax)
Immunizations for Travel
Allergy Testing (95004-95199)
Audiologic Function Test (92551-92597)
Blood Transfusions
Bronchoscopy
Cardiac Catheterization
OUTPATIENT SERVICES
Chemotherapy (includes all IM, SQ, and IV injections)
Colonoscopy, Diagnostic
Enhanced External Counter Pulsation (ECP) G0166
(limited to 35 visits per 12 month period)
Electroencephalogram (EEG) w/ video monitoring 48 hrs
