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.