Simply health care - services required authorization

All of the following procedures and services require Prior Plan Notification and must be

provided in a SHP participating facility

o Inpatient and Observation Admissions, as noted above

o Admission to any rehabilitation and skilled nursing facility

o All surgical procedures, inpatient or outpatient

o The following have special reporting requirements (refer to Forms Section):

 Abortions

 Hysterectomies

 Sterilization procedures

o Cosmetic or Reconstructive Surgery, including but not limited to:

 Breast reconstruction or reduction

 Blepharoplasty

 Venous procedures

 Sclerotherapy

o Services and items:

 Allergy (immunotherapy), exept for those services identified on the QAF

 Ambulance transportation (non emergent)

 Amniocentesis

 Cardiac and pulmonary rehabilitation programs

 Circumcisions after 12 weeks of age

 Court-ordered services

 Chemotherapy

 Dialysis

 DME, including apnea monitors and bili-blankets

 Upper endoscopies at colonoscopies at hospitals

 Genetic testing

 Gamma Knife, Cyberknife

 Hearing aids

 Home Health Services

 Hospice care

 Hyperbaric Oxygen Therapy (HBO)

 Investigational and experimental procedures and treatments

 IV Infusions

 Laboratory services in POS 22 and 24

 Lithotripsy

 Mental Health (See Mental Health Section)

 Nutritional counseling

 MRI’s, MRA’s

 Oral Surgery

 Oxygen therapy and equipment

 Out-of-Network Services

 Pain Management and or Pain Injections

 PET Scans

 Prenatal care

 Orthotics and Prosthetics, including Cranial Orthotics

 Physical, Occupational and Speech Therapy

 Radiation therapy

 SPECT scans

 Transplants and pre and post transplant evaluations

 Wound Care and wound vacuums

 Drugs that require pre-authorization

 Any services or procedures not listed on the Quick Authorization Form (QAF)