Johns Hopkins US Family Health Plan (USFHP) Outpatient Referral and Pre-Authorization Guidelines No Referral or Pre-Authorization Required • To ensure...
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Johns Hopkins US Family Health Plan (USFHP) Outpatient Referral and Pre-Authorization Guidelines Important Information
No Referral or Pre-Authorization Required
• This list is not all inclusive and is subject to Tricare Prime benefit changes • To verify benefit coverage call: 1-800-808-7347 • All CPT codes classified as Category III and all HCPCS codes classified as Unlisted by the American Medical Association require pre-authorization • JHHC medical policies may be helpful in supporting some pre-authorization requirements for certain procedures, and can be located at: www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/policies/medical%20policies/medicalpolicies.html • All services rendered by non-participating providers require pre-authorization • All procedures performed in ambulatory surgery centers (Place of Service 24) require a referral to be submitted to the health plan. Fax clinical documentation for services that require pre-authorization to: 410-762-5205 • For additional information about USFHP, refer to the website at: www.jhhc.com
• To ensure coordination of care, the referring physician must provide the member with a referral or script detailing the specialist services needed (no paperwork needs to be submitted to the health plan) Annual Routine Vision Screening (in-network providers only; Wilmer Eye Clinic and/or Block Vision providers)
Referral Required
• This section lists the services and/or plans that require a referral from the PCP or referring physician, which must be submitted to Care Management • Fax the universal referral form to Outpatient Intake Services at: 410-424-4603 • For urgent requests (delay will seriously jeopardize the life or health of a member, or severe pain), mark URGENT and fax to: 410-762-5205 or call Care Management at: 1-800-261-2421 or 410-424-4480 • Members are required to obtain a paper referral from their PCP prior to seeking specialty office care Capsule Endoscopy Dialysis External Counter Pulsation
Ambulance (non-emergent) Ambulatory Surgery Center (Place of Service 24)
Pre-Authorization Required
Occupational Therapy - initial 12 visits Physical Therapy - initial 12 visits Routine Foot Care - PVD & DM only
Carpal Tunnel Surgical Decompression Clinical Trials (including NCI trials) Cochlear Implants Continuous Glucose Monitoring CT Heart/Angiography Developmental Delay Programs including Autism Dexa Scans Diabetic Education DME/DMS* ECHO - Extended Care Health Option Exhaled Nitric Oxide Measurement Feeding Programs Genetic Testing Gynecomastia Surgery Hearing Aids (only active duty family
members covered) Home Health Care Hospice Hyperbaric Oxygen Therapy Infertility Testing and Treatment (except Artificial Insemination) Laser Treatment for Psoriasis MaterniT21 Test MEG/MSI - Magnetoencephalography MRI of Breast Nerve Conduction Velocity (NCV) Studies/EMG Neuropsychological Testing Neurostimulators Non-Pharmacologic Treatment of Acne (Acne Surgery)
Cosmetic Procedures Cryopreservation (reproductive) Diapers (including pull-ups and Depends) Electron Beam Computer Tomography Enuretic Conditioning Program (bladder training) Exercise Equipment and Devices Eye Exercises (visual training/orthoptics) Eye Glasses/Lenses
Radiofrequency Ablation for Chronic Back Pain Rhinoplasty Sclerotherapy Septoplasty Skin Tag Removal Speech Therapy TMJ Treatment Transplants (except corneal) Ultrasound/CT Scan for Bone Density Uvulectomy, Palatopharyngoplasty Varicose Vein Ligation Virtual Colonoscopy Wound Clinic > 10 Visits Wound Vac
Pre-Authorization Required Alcohol and Drug Treatment - continued care IOP - Intensive Outpatient Program Ambulatory Detox Counseling and Psychiatric Services > 8 visits Electro Convulsive Therapy Psychological Testing
Food Supplements (oral) Harvesting Eggs/Sperm Heating Pads or Lamps Hot Water Bottles Ice Bags Immunizations for Elective Travel Interferential Therapy Infant Formulas In Vitro Fertilization LAUP - Laser Assisted Uvuloplasty
LASIK Eye Surgery Light Box Therapy - Seasonal Affective Disorder (SAD) Naturopathic Treatment PET - Positron Emission Tomography for Dementia Private Duty Nursing Raised Toilet Seats Refractive Corneal Surgery S Codes (see Tricare Policy for
exceptions) Sex Change Procedure Shoes (orthopedic) Sterilization Reversal Structural Modification to the home Tricare Excluded Procedures Vitamin and Mineral Supplements (oral) Weight Management Programs Wheelchair Tray Table Whirlpools/Whirlpool Bath Equipment
• The following services are not part of the Tricare Prime benefit (see Tricare Exclusions Policies for all excluded benefits)
Breast Ductal Lavage and Fiberoptic Ductoscopy Extracorporeal Shockwave Therapy for Plantar Fasciitis Fecal DNA
Resources
Nutrition Counseling Occupational Therapy > 12 visits Oncotype Testing Orthotics* Osteogenic Stimulation for Fractures PET - Positron Emission Tomography Physical Therapy > 12 visits Plastic Surgery (excludes potentially cosmetic procedures) Prosthetics Pulmonary Rehabilitation Pulsed Dye Laser Treatment (Pulse Dye Laser for Port Wine Stain) PUVA - Phototherapy/ Photochemotherapy
• The following services are not part of the Tricare Prime benefit (see Tricare Exclusions Policies for all excluded benefits)
Abortion, elective Acupuncture Artificial Insemination Autopsy Bed Boards Bed Tray Table Category III CPT Codes (see Tricare Policy for exceptions) Chiropractic Treatment Chux Pads
Non-Covered Investigational Services
Urgent Care Centers Wound Clinic - initial 10 visits
• Members call: 410-424-4830 or 1-888-281-3186 • Providers call: 410-424-4845 or 1-800-261-2429 • Fax treatment plan to: 410-424-4839 • For Behavioral Health Provider & Appointment Locator Program call: 1-888-309-4573 • For services which require pre-authorization, the health plan will perform medical review before they are rendered No Referral Required Counseling and Psychiatric Services - initial 8 visits Alcohol and Drug Treatment - initial evaluation
Commonly Requested Non-Covered Services
Sleep Study Smoking Cessation Counseling Specialty Office Visits
• The health plan will perform medical review of requested services before they are rendered • Fax pertinent clinical documentation to Medical Review at: 410-762-5205 • The requesting provider will be notified of all pre-authorization decisions • For urgent requests (delay will seriously jeopardize the life or health of a member, or severe pain), mark URGENT and fax to: 410-762-5205 or call Care Management at: 1-800-261-2421 or 410-424-4480 • Members are required to obtain a paper referral from their PCP prior to seeking specialty office care
ABA Therapy Abortion, non-elective Alveolectomy/Alveoplasty Autologous Chondrocyte Implantation (knee) Biofeedback Blepharoplasty, Brow Ptosis, Entropion, Ectropion Bone Anchored Hearing Devices Botox Type A and B BRAC Testing Breast Reduction Bunionectomy Cardiac Exercise Program for patients with PVD Cardiac Rehabilitation
IDET - Intradiscal Electrothermal Therapy Investigational Health Services/Equipment (not FDA approved)
Pulse Electrical Stimulation for OA of the Knee Transcranial Magnetic Stimulation (TMS)
• The following resources may be helpful in meeting the needs of the EHP member and verifying benefit limitations Care Management Call: 1-800-261-2421 or 410-424-4480
Health Education Call: 1-866-391-1870
Customer Service Call: 1-800-808-7347 or 410-424-4528
JHHC Website (for providers) www.jhhc.com
Dental (Discount Network) Call United Concordia at: 1-800-332-0366
Extended Care Health Option (ECHO) Call: 1-800-261-2421; option 3 then option 5 *For related coding documents, please go to For Providers, Resources & Guidelines at: www.jhhc.com
Retail Pharmacy Locations Call Rite Aid at: 1-800-748-3243 or visit www.riteaid.com USFHP Website (for members) www.hopkinsmedicine.org/usfhp TRICARE Policy Manual manuals.tricare.osd.mil (Policy versions may vary based on the current USFHP contract) Effective January 2013
