Outpatient Referral and Pre-Authorization Guidelines Important Information • This list is not all inclusive • To verify benefit coverage call 1-800-654-9728 • All CPT Codes classified as Category III (0016T-0222T) or unlisted (i.e. 49999-69979) by the American Medical Association require Pre-Authorization • All services rendered by non-participating providers require Pre-Authorization • Laboratory, Radiology and Pharmacy policies and guidelines can be found at www.jhhc.com • For additional information about Priority Partners, refer to the website at www.jhhc.com
No Referral or Pre-Authorization Required
• For services provided in Office (Place of Service 11), Outpatient Hospital (Place of Service 22) or Ambulatory Surgery Centers (Place of Service 24) by specialties listed below, no Referral or Pre-Authorization is required unless listed in the Referral Required and/or Pre-Authorization sections • 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
Allergy Audiology > 21 years of age Blood Transfusions Cardiology Coumadin Clinics Dermatology Diabetic Education < 21 years of age
Referral Required
Dialysis Endocrinology ENT/Otolaryngology Gastroenterology General Surgery Gynecology Hematology
DME/DMS* Electron Beam Computer Tomograph External Counterpulsation Feeding Programs Food Supplements < 21 years of age Genetic Testing Gynecomastia Surgery Home Health Aides Home Health Care Hospice Hyperbaric Oxygen Therapy Laser Treatment for Psoriasis MEG / MSI- Magnetoencephalography MRI of Breast Neuropsychological Testing Neurostimulators Nutritional Counseling > 21 years of age Occupational Therapy > 21 years of age for > 6 visits Orthotics* Osteogenic Stimulation for Fractures PET - Positron Emission Tomography
Physical Therapy ≥ 21 years of age for > 6 visits Potentially Cosmetic Procedures* Private Duty Nursing < 21 years of age Prosthetics Pulmonary Rehabilitation Pulse Dye Laser for Port Wine Stain PUVA - Photochemotherapy /Phototherapy Radiofrequency Ablation for Chronic Back Pain Rhinoplasty Sclerotherapy Septoplasty Skin Tag Removal Sleep Study in Home Setting Speech Therapy > 21 years of age TMJ Treatment Transplants (except corneal) Uvulectomy, palatopharyngoplasty, LAUP (Laser Assisted Uvuloplasty) Varicose Vein Surgery Vitamin and Mineral Supplements < 21 years of age Weight Management Wound Clinic > 10 visits Wound Vac
Substance Abuse Services Notification to Health Plan Required Place of Service 22 Substance Abuse Assessment Individual Outpatient Therapy Group Outpatient Therapy
Substance Abuse Services For Services Listed Below Refer to Self-Referral Protocols All Places of Service Ambulatory Detox IOP - Intensive Outpatient Program Methadone Maintenance Partial Hospitalization
• The following services are not part of the Priority Partners benefit
Abortion Procedure (elective) Acupuncture Ambulance Outpatient, non-emergency Audiology <21 years of age (refer to DHMH) Autopsy Bed Boards Breast Ductal Lavage and Fiberoptic Ductoscopy Chiropractic Treatment > 21 years of age Cosmetic Procedures Cryopreservation (Reproductive) Dentures Exhaled Nitric Oxide Measurement Fecal DNA Food Supplements > 21 years of age Extracorporeal Shockwave Therapy for Plantar Fasciitis Grab Bars Harvesting Eggs/Sperm
Resources
Physical Therapy > 21 years of age for initial 6 visits Wound Clinic for initial 10 visits
• For Mental Health Services call Value Options at 1-800-888-1965 • For ADHD treatment by specialist contact Value Options at 1-800-888-1965 • For Substance Abuse assistance, members should call 410-424-4830 or 1-888-281-3186 • For Substance Abuse assistance, providers should call 410-424-4835 or 1-800-261-2429 • Fax Substance Abuse Treatment Plans to 410-424-4891 • Notification to the Health Plan can be made by any servicing provider • For Self-Referral Protocols go to: http://www.hopkinsmedicine.org/bin/i/l/selfreferralmar.06FINAL.pdf
Substance Abuse Services No Notification to Health Plan Required Place of Service 11, 57 and 71 Substance Abuse Assessment Individual Outpatient Therapy Group Outpatient Therapy
Commonly Requested Non-Covered Services
Pulmonology Rheumatology Urgent Care Centers Urology Vascular
• The Health Plan will perform Medical Review of the following requested services before they are rendered • Fax pertinent clinical documentation to Medical Review at 410-762-5205 • Fax documentation for all Durable Medical Equipment (DME)/Durable Medical Supplies (DMS) to Medical Review at 410-762-5250 • 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 • To check authorization status, access McNet (www.jhhcmcnet.com) or call Customer Service at 1-800-654-9728
Acne Surgery Alveolectomy/Alveoloplasty Autologous Chondrocyte Implantation (Knee) Biofeedback Blepharoplasty, Brow Ptosis, Entropion, Ectropion BAHA - Bone Anchored Hearing Devices Botox Type A&B Breast Reduction Bunionectomy Capsule Endoscopy Cardiac Exercise Program for Patients with PVD Cardiac Rehabilitation Carpel Tunnel Surgical Decompression Chiropractic Treatment < 21 years of age Clinical Trials Cochlear Implants Continuous Glucose Monitoring CT Heart / Angiography Developmental Delay Programs Including Autism Dexa Scan Diabetic Education > 21 years of age
Behavioral Health
Oral Surgery Orthopedics Pain Management Perinatology Plastic Surgery Podiatry Routine Foot Care PVD & DM Diagnosis Only
• Fax the universal referral form for services listed below for Office (Place of Service 11) or Outpatient Hospital (Place of Service 22) settings 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 410-424-4603 or call Care Management at 1-800-261-2421 or 410-424-4480
Obstetrical Care (global pregnancy) Occupational Therapy > 21 years of age for initial 6 visits
Pre-Authorization Required
Infectious Disease Nephrology Neurology Nutritional Counseling < 21 years of age Oncology Ophthalmology
Hearing Aids > 21 years of age Heating Pads or Lamps Hot Water Bottles Ice Bags IDET - Intradiscal Electrothermal Therapy Interferential Therapy Investigational/Experimental Health Services (not FDA Approved) Infertility Services In Vitro Fertilization Immunizations for Elective Travel Impotence Therapy LASIK Surgery Learning Disabilities (refer to school system) Massage Therapy Naturopathic Treatments Occupational Therapy < 21 years of age (refer to DHMH)
Orthodontia > 21 years of age Private Duty Nursing > 21 years of age Physical Therapy < 21 years of age (refer to DHMH) Podiatry - Routine Foot Care - Except PVD and DM Diagnosis Only Pulse Electrical Stimulation for OA of the Knee Raised Toilet Seats Sex Change Procedures Smoking Cessation Counseling Speech Therapy < 21 years of age (refer to DHMH) Sterilization Reversal Ultrasound/CT Scan for Bone Density Vitamin and Mineral Supplements ≥ 21 years of age Tray Tables Wheelchair Tray Table Whirlpools/Whirlpool Bath Equipment
• The following resources may be helpful in meeting the needs of the Priority Partners member
ACCU-CHECK - Member needs to call 1-888-355-4242 to request a voucher to take to pharmacy Audiology (including hearing aids), Occupational, Physical, and Speech therapy < 21 years of age - call DHMH at 1-877-463-3464 Care Management - call 1-800-261-2421 or 410-424-4480 Customer Service - call 1-800-654-9728 Dental Services/Pregnant Women & Children - call DentaQuest at 1-888-696-9596 Dental Services/Adults - call DentaQuest at 1-800-698-9611 Pharmacy Pre-Authorization Requests - call Pharmacy Department at 1-888-819-1043, option 4 Private Duty Nursing <21 years of age - call Pediatric Health Partners at 410-762-5280 Priority Partners Website - www.ppmco.org *For related coding documents, please go to www.jhhc.com, Providers & Physicians, Priority Partners, Resources & Guidelines. Revised UM3; Effective January 2011
