Prior Authorization

Prior Authorization Lookup Tool

Prior authorization is required for all services provided by non-participating physicians and providers, with the exception of emergency services. Prior authorization is also required for other services such as those listed below. To submit a request for prior authorization providers may

Medical services (excluding certain radiology – see below):

Behavioral health services:

Home Health Services contact tango:

  • Call 1-888-705-5274.
  • Provider Portal – ProNet Connect.

Radiological Services:

  • For the following non-emergent outpatient radiological procedures contact National Imaging Associates, Inc. (NIA) at 1-866-272-4086 or visit www.radmd.com:
    • CT/CTA
    • CCTA
    • MRI/MRA
    • PET Scan
    • Myocardial Perfusion Imaging
    • MUGA Scan

Pharmacy Services:

For prescription drugs not found on our formulary, an exception can be requested by completing the following:

If the request is denied, you can request an appeal on the member's behalf by completing the following:

Please remember to submit all relevant clinical documentation to support the requested services/items at the time of your request.

Services that require Prior Authorization by Keystone First VIP Choice

  • All out-of-network services (excluding emergency services).
  • All inpatient hospital admissions, including medical, surgical, skilled nursing, and rehabilitation.
  • Elective transfers for inpatient and/or outpatient services between acute care facilities.
  • Inpatient services.
  • Surgery.
  • Surgical services that may be considered cosmetic, including but not limited to:
    • Blepharoplasty.
    • Mastectomy for gynecomastia.
    • Mastopexy.
    • Maxillofacial.
    • Panniculectomy.
    • Penile prosthesis.
    • Plastic surgery/cosmetic dermatology.
    • Reduction mammoplasty.
    • Septoplasty.
    • Gastric bypass/vertical band gastroplasty.
  • Transplants, including transplant evaluations.
  • Certain outpatient diagnostic tests.
  • Radiology outpatient services (authorized by NIA):
    • CT scan.
    • PET scan.
    • MRI.
    • MRA.
    • MRS.
    • SPECT scan.
    • Nuclear cardiac imaging.
  • Ambulance:
    • Elective/nonemergent air ambulance transportation.
    • Certain types of scheduled, nonemergency ambulance trips.
  • Home health (authorized by tango).
  • Cardiac and pulmonary rehabilitation.
  • Speech therapy, occupational therapy, and physical therapy provided in home or outpatient setting, after the first visit, per therapy discipline/type.
  • Durable medical equipment (DME):
    • All DME rentals and rent-to-purchase items.
    • Purchase of all items in excess of $500 in total billed charges.
    • Prosthetics and orthotics in excess of $500 in total billed charges.
    • The purchase of all wheelchairs (motorized and manual) and all wheelchair accessories (components), regardless of cost per item.
  • Medications: All infusion/injectable medications listed on the Medicare Professional Fee Schedule — infusion/injectable medications not listed on the Medicare Professional Fee Schedule are not covered.
  • Pain management — external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation, and injections/nerve blocks,
  • Nutritional supplements.
  • Hyperbaric oxygen.
  • Religious Non-Medical Health Care Institutions (RNHCI).
  • All "miscellaneous", "unlisted", or "not otherwise specified" codes.
  • All services that may be considered experimental and/or investigational.
Providers