Prior Authorization

Prior Authorization is based on a combination of medical necessity, medical appropriateness and benefit limits. Our Covered Services Grid indicates which services require Prior Authorization.

Services that Require Prior Authorization
How to Request Prior Authorization
Unlisted CPT Codes
Referrals

New PA on Pain Management Procedures - July 1, 2011

Effective July 1, 2011, CareSource is implementing a policy change that will now require prior authorization for some interventional pain management procedures. Also included in this policy is a change in authorization for associated anesthesia services.

Procedures and CPT Codes Affected by this Policy Change

• Soft Tissue and Trigger Point Injections: Maximum of 8 injections in a 12 month period by the same or multiple providers. CPT Codes: 20550, 20551, 20552, 20553
• Facet Joint and/or Facet Joint Nerve Injection: Greater than 6 injections in a 12 month period by the same or multiple providers require prior authorization. CPT Codes: 64490, 64491, 64492, 64493, 64494, 64495
• Epidural Steroid Injection and Selective Transforaminal Epidural Injection: Greater than 3 injections in a 12 month period by the same or any provider require prior authorization. CPT Codes: 62310, 62311, 64479, 64480, 64483, 64484.
• Sacroiliac Joint Injection: Greater than 6 injections in a 12 month period require prior authorization. CPT Codes: 27096
• Monitored Anesthesia: Monitored anesthesia will not be authorized for any interventional pain management procedures listed above. Conscious sedation, if preferred, does not require prior authorization, but services will be considered part of the procedure and are not eligible for additional reimbursement. CPT Codes: 01991, 01992, 01935, 01936

For more details, visit our Medical Policies section.

Services that Require Prior Authorization Before the Service is Provided:

• All Inpatient Care
• All Abortions
• All Home Care Services
• Nursing Facility Services
• Inpatient Rehabilitative Services
• Organ Transplants
• Durable Medical Equipment over $750 billed charges
  • The $750 rule does not apply to the DME/other items (below)– these require prior authorization:
    • All powered or customized wheelchairs
    • Manual wheelchair rentals over 3 months
    • All miscellaneous codes (example E 1399)
• Cosmetic procedures and plastic surgery
• Some specialty drugs
• Non-Formulary Drug Requests
• Ambulance and ambulette transportation – except for emergent or facility-to-facility transfers
• Diagnostic Procedures
  • MRI's
  • PET scan
  • Gastrointestinal Tract Imaging (video capsule)
• Pain management/clinic
  • Spinal Injections and Blocks
• Rehabilitative services
  • Physical therapy over 18 visits per calendar year
  • Occupational therapy over 18 visits per calendar year
  • Speech therapy
• Food Supplements/nutritional supplements
• All services rendered by non-participating Providers
  • All services rendered by non-participating Providers -Outpatient obstetrical services rendered by non-participating Providers to pregnant Members do not require Prior Authorization.

Submit Prior Authorization:

• By phone -1-800-390-7102
• By fax - Fax Prior Authorization requests to 1-888-577-5507
• By mail - Send Prior Authorization requests to:

CareSource
Attn: Medical Services Department
P.O. Box 1307
Dayton, OH 45401-1307

Written Prior Authorization requests should be submitted on the Prior Authorization Request Form.

PA and Unlisted CPT Codes

CareSource does not require prior authorization for unlisted procedure CPT codes. However, we require a clinical record be submitted with your claim to review the validity of the unlisted procedure CPT code. Claims submitted without clinical records for unlisted procedure CPT codes will be denied. Denials will be reconsidered through the appeal process with pertinent clinical records.

Note: Authorizations are not a guarantee of payment. Authorizations are based on medical necessity and are contingent upon eligibility and benefits (and other factors). Benefits may be subject to limitations and/or qualifications and will be determined when the claim is received for processing.

Referral to a Specialist

CareSource uses a paperless referral system to make it easy for Primary Care Providers (PCPs) to refer their patients to participating specialists. To make a referral, PCPs simply:

• Document the referral in the member's medical chart. Please note the number of visits or length of time for each referral
• Tell the member how to get the service
• Notify the specialist of the referral

PCPs are not required to use a referral form or send a copy of it to CareSource. They also do not have to get Prior Authorization to make a referral to a participating specialist.

To receive a referral from a PCP, specialists simply document in the patient's medical chart that the patient was referred for services. Please note the number of visits or length of time for each referral. Referral numbers are not required on claims submitted for referred services.

Please remember that only PCPs can issue referrals to additional specialists. Generally, specialist-to-specialist referrals are not allowed. However, in some cases, specialists may provide services or make referrals in the same manner as a PCP.

For more information about which services require a referral, please see Provider Manual.

Post Stabilization Services - Please call 1-800-390-7102 for post stabilization services if the member requires inpatient care for covered services related to an emergency medical condition that a treating provider views as medically necessary after an emergency medical condition has been stabilized in order to maintain the stabilized condition, or under the circumstances described in 42 C.F.R. 422.113 to improve or resolve the member's condition. Such services shall be deemed prior authorized if CareSource does not respond within the one-hour timeframe for responding to a request for authorization being made by the emergency department.