Prior Authorization

Prior authorization lookup tool

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.

Prior authorization request forms

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 a lesser intensity than that received in a hospital, not to include long-term care placements.
  • Select gastroenterology services.
  • 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, including 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.
  • Home health services performed by a network provider.
    • Prior authorization is not required for up to 18 visits per modality per calendar year, including: skilled nursing visits by an R.N. or L.P.N.; home health aide visits; physical therapy; occupational therapy; speech therapy; home respiratory therapy; mechanical ventilation care; stoma care and maintenance, including colostomy and cystectomy; and services of clinical social workers in home health or hospice settings.
    • The duration of services may not exceed a 60-day period. The Participant must be re-evaluated every 60 days.
    • All shift care/private duty nursing services require prior authorization, including services performed at a medical day care.
    • Injectables.
    • Home sleep study.
  • Durable medical equipment (DME) monthly rentals regardless of the per month/cost charge.
  • DME purchases:
    • Purchase of all items in excess of $750.
    • The purchase of all wheelchairs (motorized and manual) regardless of cost per item.
    • Select wheelchair items (components).
    • Enterals:
      • Prior authorization is required. 
    • Diapers/Pull-ups
      • Any request in excess of 300 diapers or pull-ups per month or a combination of both requires prior authorization.
      • Any request in excess of 300 diapers or pull-ups or a combination of both will be reviewed for medical necessity.
      • Requests for brand-specific diapers require prior authorization.
      • Requests for diapers supplied by a DME provider. Refer to the DME section of the Provider Manual for complete details.
  • Select radiological exams ― excludes radiological studies that occur during inpatient, emergency room, and/or observation stays.
    • Positron emission tomography.
    • Magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA).
    • Nuclear cardiology diagnostic testing.
    • Computed axial tomography (CT/CAT scans) and CT angiography.
  • Cardiac or pulmonary rehabilitation.
  • Chiropractic manipulative treatment for Participants older than 18 (only codes 98940, 98941, and 98943).
  • Any service(s) performed by nonparticipating 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 Health and Human Services fee schedule, benefit limits, and regulation (regardless of cost, i.e., above or below the $750 DME threshold).
  • 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 prior authorization, please refer to the Dental Services section of the Provider Manual.
  • Elective termination of pregnancy ― refer to the Termination of Pregnancy section of the Provider Manual for complete details.
  • Home modifications.

Prior authorization is not a guarantee of payment for the service(s) authorized. The plan 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 1-800-521-6622.

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.