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 nonemergent 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 cesarean 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.
• Hyperbaric oxygen.
• 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.
• Surgical services that may be considered cosmetic, including but not limited to:
  • Blepharoplasty.
  • Mastectomy for gynecomastia.
  • Mastopexy.
  • Maxillofacial surgery.
  • 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.