View services that require prior authorization for your HealthFirst
2015 Prominence Health Plan HMO/POS Prior Authorization List Health Services: 775-770-9350 24-hour Confidential FAX: 775-770-9364 All requested services must be medically necessary and are subject to benefit coverage. The member is responsible for checking the summary of benefits for his/her plan or may call Member Services for benefit verification. Documentation is required for out-of-network exceptions. For continuity and coordination of care, consultative reports are to be provided to other treating providers as needed. Prior authorization status is available on the Prominence Health Plan secure member/provider web portal. NOTE: Clinical preventive services must meet current US Preventive Services Task Force (USPSTF) Guidelines: www.uspreventiveservicestaskforce.org. Specialty Provider Services and Procedures REQUIRING Prior Authorization (PA) by Prominence Health Plan’s Utilization Management Department Prior Authorization Required Admission to an Inpatient or Outpatient Facility - includes all surgeries; inpatient skilled nursing and acute rehabilitation Comments Does not include OB delivery Botox injections Contact Health Help for prior authorization for the following: CT, CTA, MRA, MRI, Nuclear Med Cardiac, PET, MUGA, radiation oncology, medical oncology, Spine care (relating to neck & back, including surgery, epidurals, triggerpoint Injections) Contact HealthHelp (Radiology Consult) 877-392-0574 or fax 877-392-0573 or online at www.healthhelp.com/prominencehealthplan Dental care, oral surgery, TMJ services, oral appliances (including sleep apnea appliances) Sleep study required for sleep apnea (OSA) appliance. Call Member Services at 775-770-9310 to confirm benefits and limitations. Dermatology DME/Orthotics/Prosthetics more than $500 See PDF DME PA required list available online Genetic Counseling & Genetic Testing Hyperbaric Oxygen Therapy Infusion Therapy Outpatient only Mental Health/Substance Abuse: Inpatient and Day Treatment (partial hospital) & Electroconvulsive Therapy (ECT) Nutritional Supplements: Enteral/Parenteral & Nutrition, Special Foods for inherited metabolic disorders Contact: Magellan Health Services 800-245-7013 or Fax 443-896-1454 www.magellanassist.com Out of network / out of plan referral and services 3-D OB Ultrasound Plastic and reconstructive surgery Reproductive Endocrinology: Artificial Insemination services and Fertility Testing Transplants and all related services Network provider only Varicose vein surgery PA required for surgical treatment and sclerotherapy Member Services Provider Line: For benefits, limitations and eligibility call 775-770-9310 or 886-500-2741 You may request and receive authorization online via the secure provider portal at www.prominencehealthplan.com Providers new to provider online services call 775-770-9311 Online prior authorization at www.prominencehealthplan.com/providers Prominence Health Plan HealthFirst HMO/POS Prior Authorization List REV MAY 2015
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