Prior authorization is not a guarantee of payment for the services authorized. Keystone First Community HealthChoices (CHC) reserves the right to adjust any payment made following a review of medical record and determination of medical necessity of services provided.
Any additional questions regarding prior authorization requests may be addressed by calling Keystone First's Utilization Management/Prior Authorization line at 1-800-521-6622.
All LTSS services require prior authorization. Refer to the LTSS section of the Provider Manual for a list of LTSS services that require prior authorization.
Physical health services that require prior authorization
- All elective (scheduled) inpatient hospital admissions, medical and surgical including rehabilitation.
- All elective transplant evaluations and procedures.
- Elective/non-emergent Air Ambulance Transportation.
- All elective transfers for inpatient and/or outpatient services between acute care facilities.
- Skilled Nursing facility admission for alternate levels of care in a facility, either free-standing or part of a hospital, that accepts patients in need of skilled level rehabilitation and/or medical care that is of lesser intensity than that received in a hospital, not to include long term care placements.
- Gastroenterology services (codes 91110 and 91111 only).
- Bariatric surgery.
- Pain management services performed in a short procedure unit (SPU) or ambulatory surgery unit (either hospital-based or free-standing) and pain management services not on the Medical Assistance fee schedule performed in a physician's office.
- Cosmetic procedures regardless of treatment setting to include, but not limited to the following: reduction mammoplasty, gastroplasty, ligation and stripping of veins and rhinoplasty.
- Outpatient Therapy Services (physical, occupational, speech).
- Prior authorization is not required for an evaluation and up to 24 visits per discipline within a calendar year.
- Prior authorization is required for services exceeding 24 visits per discipline within a calendar year.
- Cardiac and Pulmonary Rehabilitation.
- Chiropractic services after the initial visit.
- Home Health Services.
- Prior authorization is not required for up to 6 home visits per modality per calendar year including: skilled nursing visits by a RN or LPN; Home Health Aide visits; Physical Therapy; Occupational Therapy and Speech Therapy.
- The duration of services may not exceed a 60 day period. The Participant must be re-evaluated every 60 days
- All Shiftcare/Private Duty Nursing services, including services performed at a medical daycare or Prescribed.
- Extended Care Center.
- Home Sleep Study.
- Purchase of all items in excess of $750.
- DME monthly rental items regardless of the per month cost/charge.
- The purchase of all wheelchairs (motorized and manual) and all wheelchair items (components) regardless of cost per item.
- The rental of all wheelchairs (motorized and manual) and all wheelchair items (components) regardless of cost per item.
- Any request in excess of 300 a month for diapers or pull-ups or a combination of both.
- Requests for brand specific diapers.
- Any service(s) performed by non-participating or non-contracted practitioners or providers, unless the service is an emergency service.
- All services that may be considered experimental and/or investigational.
- Neurological Psychological Testing.
- Genetic Laboratory Testing.
- All miscellaneous/unlisted or not otherwise specified codes.
- Any service/product not listed on the Medical Assistance Fee Schedule or services or equipment in excess of limitations set forth by the Department of Human Services fee schedule, benefit limits and regulation. (Regardless of cost, i.e., above or below the $750 DME threshold.)
- Radiology - The following services, when performed as an outpatient service, requires prior authorization by the Plan's radiology benefits vendor. Refer to the Radiology Services section of the Provider Manual for prior authorization details.
- Positron Emission Tomography (PET).
- Magnetic Resonance Imaging (MRI)/Magnetic Resonance Angiography (MRA).
- Nuclear Cardiology /MPI.
- Computed Axial Tomography (CT/CTA/CCTA).
Emergency room, Observation Care and inpatient imaging procedures do not require Prior Authorization.
- Select prescription medications. For information on which prescription drugs require authorization, see the Searchable Formulary.
- Select dental services. For information on which dental services require authorization, please refer to the Dental Provider Supplement(PDF).
- Elective termination of pregnancy – Refer to the Termination of Pregnancy section of the Provider Manual for complete details.
Participants with Medicare coverage may go to Medicare Health Care Providers of choice for Medicare covered services, whether or not the Medicare Health Care Provider has complied with the Plan's Prior Authorization requirements. The Plan's policies and procedures must be followed for Non-Covered Medicare services.