Prior authorization information - Select Health of South Carolina
PriorAuthorizationInformation2015 DOES NOT Require Prior Authorization • Emergency ground transportation (ALS, BLS) • Emergency department services • Participating gynecological and specialty physician office visits • X-rays Contacts Medical Services: Phone: 1.888.559.1010 Fax: 1.866.368.4562 Notification REQUIRED • Normal newborn deliveries • Maternity observation Services REQUIRING PRIOR AUTHORIZATION Inpatient Pain Management • Inpatient services • All inpatient hospital admissions, including • External infusion pumps, spinal cord, neurostimulators, medical, surgical and rehabilitation • Behavioral health • Non-participating providers • Obstetrical outpatient services, admissions, observations, diabetic education and abnormal newborn deliveries • Services rendered by specialists for obstetrical patients (i.e. maternal fetal medicine, endocrinologist, cardiologist, etc.) National Imaging Associates (NIA) Website: www.RadMD.com Phone: 1.800.424.4895 PerformRx: Phone: 1.866.610.2773 Fax: 1.866.610.2775 Behavioral Health: Phone: 1.888.559.1010 Fax: 1.888.796.5521 Claims: Phone: 1.800.575.0418 Phone: 1.800.741.6605 Address: Claims Processing Dept. PO Box 7120 London, KY 40742 Website: www.selecthealthofsc.com Visit NaviNet to verify member eligibility and claim status: navinet.navimedix.com Disclaimer: Telephone or written approval is not a guarantee of reimbursement. All services are subject to retrospective review to validate the request. This list is NOT all inclusive. • Medical detoxification • Elective transfers for inpatient and/or outpatient services between acute care facilities • Skilled nursing facility • Long-Term care initial placement (for acute services if still enrolled with the plan) Services • Air ambulance (reviewed retrospectively) • Behavioral health (Psychological and neuropsychological testing, ECT, environmental intervention, interpretation or explanation of results, unlisted psychiatric services) • Capsule endoscopy • Cardiac rehabilitation (all services) • Chiropractic care (six visits per fiscal year, July 1 through June 30) • Circumcisions (unless performed prior to delivery discharge) • Cochlear implantation, insertion (covered for members under 21) • Contact lenses (including dispensing fees) • Gastric bypass/vertical band gastroplasty • Holter monitors (event recorder monitors) Durable Medical Equipment • Items with billed charges equal to or greater than $500 (total for each DME item), including prosthetics and orthotics • All DME leases or rentals • All enteral nutritional supplements and supplies • All wheelchair parts (manual and power) • Insulin pumps • Thoracolumbosacral orthosis (TLSOs - back braces) • All unlisted or miscellaneous items regardless of cost Home-Based Services • Home health care—after 6 visits • Home assessment • Home infusion services and injections (equal to and greater than $250) Select Health of South Carolina PO Box 40849, Charleston, SC 29423 We help people get care, stay well and build healthy communities. Last revised 04/30/15 implantable infusion pumps, radiofrequency ablation nerve blocks and spinal injections Plastic Surgery Surgical services that may be considered cosmetic, including: • Blepharoplasty • Mastectomy for gynecomastia • Mastoplexy • Maxillofacial—all codes applicable • Panniculectomy • Penile prosthesis • Plastic surgery/cosmetic dermatology • Reduction mammoplasty • Septoplasty (except submucous resection, with/without cartilage scoring) Therapy and Related Services • Speech therapy—authorization required for all visits after initial evaluation/re-evaluation (private therapy only) st 12 visits • Speech therapy—after evaluation and 1 (facility only) • Occupational and physical therapy—after evaluation and 1st 12 visits for each modality (facility and private therapy) Pharmacy and Medications Contact PerformRx: • Medications (infusions, injectable drugs, chemotherapy, PO and IV) with billed amount equal to or greater than $250 • Medications not listed on the South Carolina Medicaid Professional Services Fee Schedule are not covered by First Choice Advanced Outpatient Imaging Services • Nuclear Cardiology • Computed Tomography Angiography (CTA) • Coronary Computed Tomography Angiography (CCTA) • Computed Tomography (CT) • Magnetic Resonance Angiography (MRA) • Magnetic Resonance Imaging (MRI) • Myocardial Perfusion Imaging (MPI) • Positron Emission Tomography (PET) Contact National Imaging Associates (NIA): www.RadMD.com or call 1.800.424.4895.
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