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Prior Authorization

Prior authorization is required to see out-of-network providers, with the exception of emergency services. To submit a request for prior authorization, providers may:

  • Call the prior authorization line at 1-855-294-7046 (*for behavioral health requests call 1-866-688-1137);
  • Fill out this form (PDF) and fax it to 1-855-809-9202 (for behavioral health requests, fax to 1-855-396-5740).

Services that require prior authorization by Keystone First VIP Choice (HMO SNP)**

  • Elective or non-emergent air ambulance transportation.
  • All out-of-network services (excluding emergency services).
  • In patient services:
    • All in patient hospital admissions, including medical, surgical, skilled nursing, and rehabilitation.
    • Obstetrical admissions and newborn deliveries exceeding 48 hours after vaginal delivery and 96 hours after Caesarean section.
    • Inpatient diabetes programs and supplies.
    • In patient medical detoxification.
    • Elective transfers for inpatient and/or outpatient services between acute care facilities.
  • Certain outpatient diagnostic tests.
  • Home health.
  • Therapy and related services:
    • Speech therapy, occupational therapy and physical therapy provided in a home or outpatient setting, after the first visit per therapy discipline or type.
    • Chiropractic services.
    • Cardiac and pulmonary rehabilitation.
  • Transplants, including transplant evaluations.
  • All durable medical equipment (DME) rentals and rent-to-purchase items.
  • DME, medical supply, prosthetic device purchases:
    • Purchase of all items in excess of $500 in allowable charges.
    • Prosthetics and orthotics in excess of $500 in allowable charges.
    • The purchase of all wheelchairs (motorized and manual) and all wheelchair accessories (components) regardless of cost per item.
    • Nutritional supplements.
  • Hyperbaric oxygen.
  • Surgery for sleep apnea (uvulopalatopharyngoplasty (UPPP)].
  • Religious non-medical health care institutions (RNHCIs).
  • Medications — 17-P and all infusion or injectable medications listed on the Medicare Professional Fee Schedule; infusion or injectable medications not listed on the Medicare Professional Fee Schedule are not covered by Keystone First VIP Choice (HMO SNP).
  • Surgical services that may be considered cosmetic, including but not limited to:
    • Blepharoplasty.
    • Mastectomy for gynecomastia.
    • Mastopexy.
    • Maxillofacial.
    • Panniculectomy.
    • Penile prosthesis.
    • Plastic surgery or cosmetic dermatology.
    • Reduction mammoplasty.
    • Septoplasty.
  • Cochlear implantation.
  • Gastric bypass or vertical band gastroplasty.
  • Hysterectomy.
  • Pain management — External infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation, and injections or nerve blocks.
  • Radiology outpatient services:
    • Computed tomography scan.
    • Positron emission tomography scan.
    • Magnetic resonance imaging.
    • Magnetic resonance angiography.
    • Magnetic resonance spectroscopy.
    • Single-photon emission computed tomography scan.
    • Nuclear cardiac imaging.
  • All miscellaneous/unlisted or not otherwise specified codes.
  • All services that may be considered experimental and/or investigational.

**All requests for services are subject to Medicare coverage guidelines and limitations.

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