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Prior Authorization

Prior authorization is the process of obtaining approval in advance of certain services such as an inpatient admission or durable medical equipment. Prestige Health Choice will make an authorization decision based on the clinical information provided in the request.

Reasons for requiring authorization may include:

  • Review for medical necessity.
  • Appropriateness of rendering provider.
  • Appropriateness of setting.
  • Case and disease management considerations.

Services requiring prior authorization

All services listed below require prior authorization. Refer to the comments for additional details specific to each service.

Florida Medicaid regions 9 and 11 effective December 1, 2018 for SMMC Contract FP070.

This authorization grid applies to all contracted providers in Florida Medicaid regions 9 and 11 who provide services pursuant to the 2018 – 2023 Statewide Medicaid Managed Care contracts. Non-participating providers must seek authorization for all services provided, with the exception of emergency services.

Service type Comments
Abortions, elective  
Admissions — inpatient Includes surgical, medical, and inpatient medical detoxification and rehabilitation; obstetrical admissions and newborn deliveries exceeding 48 hours after vaginal delivery and 96 hours after cesarean section; and admissions to nursing facilities.
Air ambulance  
Bariatric surgery/gastric bypass  
Chemotherapy Please refer to the list of specific HCPCS codes requiring prior authorization (PDF).
Chiropractic services Under age 21 only.
Circumcision Prior authorization is required if the member is more than 90 days old.
Cochlear implants or implantation  
Dermatology Only surgery or procedures that could be considered cosmetic require prior authorization.
Diapers and pull-up diapers Please contact Coastal Care Services at 1-855-481-0505* regarding authorization of durable medical equipment (DME) and supplies provided in the home (i.e., place of service [POS] 12).

Limited to ages 4 through 20 when medically necessary.

DME and supplies Please contact Coastal Care Services at 1-855-481-0505* regarding authorization of DME and supplies provided in the home (i.e., POS 12).
For authorization requests not handled by Coastal Care Services:
  • Prior authorization is required for all rentals and custom equipment, including items related to or part of the rental or custom equipment.

Purchase items with billed charges of $750 or greater per line item require prior authorization; this includes non-custom orthotics.

Elective transfers for inpatient (IP) and/or outpatient (OP) services between acute care facilities  
Enteral feedings Including related DME.
Gastric bypass/vertical band gastroplasty  
Home health services Contact Coastal Care Services at 1-855-481-0505 for authorization requests.*
Hyperbaric oxygen therapy  
Hysterectomy  
Implants Prior authorization needed only when billed charges are $750 or greater per line item.
Infusion or injectable medications in home Please refer to the list of specific HCPCS codes requiring prior authorization (PDF).
Contact Coastal Care Services at 1-855-481-0505 for authorization requests.*
Insulin pumps Considered under DME benefit.
Medications Please refer to the list of specific HCPCS codes requiring prior authorization (PDF). For pharmacy medication authorization requirements, refer to the Agency for Health Care Administration's (AHCA) drug prior authorization criteria.
Non-participating/out-of-network services (all services)  
Oral or maxillofacial surgery For services performed in a dental office, please contact the member’s assigned dental plan. For medical services, please contact Prestige Health Choice.
Orthotics and prosthetics (custom) All custom orthotics and prosthetics require prior authorization.
Pain management External infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation, and nerve blocks.
Personal care services When medically necessary for members under age 21.
Private duty nursing When medically necessary for members under age 21.
Radiology — advanced (computed tomography [CT], magnetic resonance imaging [MRI], magnetic resonance angiography [MRA], positron emission tomography [PET] scan, nuclear cardiac imaging).  
Surgical services that may be considered cosmetic Includes, but is not limited to, blepharoplasty, mastectomy for gynecomastia, mastopexy, maxillofacial surgery, panniculectomy, penile prosthesis, reduction mammoplasty, and septoplasty.
Therapy — physical therapy (PT), occupational therapy (OT), speech therapy (ST) Under age 21, prior authorization required for visits only, not for evaluations.
Over age 21, refer to the expanded benefits section below.
Transplants  
Unlisted, miscellaneous, and manually priced codes (including, but not limited to, codes ending in “99”)  

Expanded benefits requiring authorization

Service type Comments
Medically related home care services — Homemaker One carpet cleaning per calendar year for adults with asthma; annual dollar max of $100 per calendar year; must be from approved vendor list. Will require Care Management referral.
Home-delivered meals (general) For 30 days; limited to high-risk pregnant members who meet plan guidelines for medical necessity; will require Care Management referral.
Home-delivered meals — Post-facility discharge (hospital or nursing facility) Up to two meals per day for up to seven days for members who have been recently discharged from the hospital with specific medical conditions. Will require Care Management referral. Extension of services may be granted with Medical Director approval.
Home health nursing/aide services Provide up to 48 visits per pregnancy for home health aide; limited to high-risk pregnant members who meet plan guidelines for medical necessity; requires a physician order. Contact Coastal Care Services at 1-855-481-0505* for authorization requests.
Home visit by a clinical social worker Limited to 24 visits per calendar year for high-risk pregnant members; requires physician order. Will require Care Management referral for a participating provider. Contact Coastal Care Services at 1-855-481-0505* for authorization requests.
Housing assistance Provide assistance with locating community resources that support housing options and alternatives for all members; provide up to $500 per lifetime max for transitional housing alternatives; financial assistance is limited to high-risk pregnant members who are homeless. Will require Care Management referral.
Massage therapy Maximum of 12 visits per calendar year for medical massage provided by a participating physical therapy or chiropractic provider. Prior authorization required for physical therapist. No prior authorization required when provided by a chiropractor.
Meals — non-emergency transportation day trips Please contact Access2Care at 1-855-381-3778. Limited to $50 per day with annual max of $250.
Outpatient hospital services All medically necessary outpatient hospital services are excluded from the $1500 outpatient maximum reimbursement cap.
Swimming lessons (drowning prevention) There will be an open enrollment for up to 1,000 children each April. Up to $200 per child will be paid to a plan-approved agency and/or certified instructor. Requires Care Management referral for payment to approved agency provider.
Therapy — Art Up to seven sessions per calendar year on outpatient basis.
Therapy — Equine Up to three session per calendar year; member must be in care management or disease management program with a diagnosis of substance use disorder or a chronic condition; outpatient setting.
Therapy — Pet Up to three sessions per calendar year; member must be in care management or disease management program with a diagnosis of a chronic condition; services provided in an Inpatient setting while member is in an acute care hospital for treatment.
Prenatal/perinatal Hospital-grade breast pump. Max of one per calendar year.
Please contact Coastal Care Services at 1-855-481-0505* regarding authorization of DME and supplies provided in the home (i.e., POS 12).
Therapy — PT, ST, or OT (over age 21) Prior authorization required for visits only, not for evaluations. Limited to one evaluation per calendar year, and up to seven therapy treatment units per week.
Adult vision services Please contact Premier Eye Care of Florida at 1-800-738-1889.
Adult hearing services Please contact HearUSA at 1-800-731-3277.
DME and supplies For members 21 and over:
Please contact Coastal Care Services at 1-855-481-0505* regarding authorization of DME and supplies provided in the home (i.e., POS 12).
For authorization requests not handled by Coastal Care Services:
  • Prior authorization is required for all rentals and custom equipment, including items related to or part of the rental or custom equipment.
  • Purchase items with billed charges of $750 or greater per line item require prior authorization; this includes non-custom orthotics.
Behavioral health — assessment services and intensive outpatient treatment Please contact Optum at 1-855-371-3967.

*Coastal Care Services manages all of Prestige Health Choice’s DME, home health, and home infusion services provided in the home with the exception of those listed below. When rendered in place of service 12 (home), the following specific excluded services should be authorized by and billed to Prestige Health Choice:

  • Communication boards.
  • All contraceptive medications and supplies.
  • Cranial helmets.
  • All end-stage renal disease (ESRD) services rendered in the home.
  • Implantable device supplies (examples include supplies related to cochlear implants, permanent birth control, and urogynecologic surgical mesh implants).
  • Inhalation solution (solution/drug should be obtained through member's pharmacy benefit).
  • OB/GYN home health services (provided by Optum Women and Children).
    • Please contact Optum directly by phone at 1-855-371-3967 or via fax at 1-678-355-4711 prior to providing these services.
  • Orthotics/prosthetics.
  • Vision, hearing, and speech pathology services (HCPCS codes in the "V" series).

All services not rendered in place of service 12 (home) should be billed to Prestige Health Choice.

Prestige Health Choice works with subcontractors to help manage some services for Prestige Health Choice members. For prior authorization requirements for these services, please see below:

The prior authorization request should include the diagnosis to be treated and the CPT and HCPCS code describing the anticipated procedure or service. If the procedure performed and billed is different from that on the request, but within the same family of services, a revised authorization is not typically required. If an adjustment is needed following delivery of the service, please contact the Utilization Management Department on the next business day at 1-855-371-8074.

An authorization may be given for a series of visits or services related to an episode of care. The authorization request should outline the plan of care including the frequency and total number of visits requested and the expected duration of care.

Time frame for standard authorization requests

Prestige Health Choice has seven calendar days to render a decision from the date of a standard authorization request and can extend the time frame by an additional seven calendar days. If the time frame is extended, a notice will be sent to the enrollee within five business days of determining the need for an extension.

Time frame for expedited authorization requests

Prestige Health Choice will render a decision on expedited requests within 48 hours of receipt and can extend the time frame by an additional two calendar days. Expedited requests must include a physician’s order which indicates waiting for a decision under the standard time frame could endanger the member’s life, health, or ability to regain maximum functionality, or would cause serious pain. Requests received without this order will be handled under the standard time frame. If the time frame is extended, a notice will be sent to the enrollee within five business days of determining the need for an extension.

Providers may submit prior authorization requests:

  • Online via the Availity website.
  • By fax using the fax number at the top of the appropriate prior authorization request forms below.

Please note that home care requests, such as for DME, home health care services, and home infusion medication, must all be received via fax with all necessary clinical information, including physician orders, using the designated fax number located on the appropriate prior authorization form.

Medication requests

The process to submit requests for medication with HCPCS codes that require prior authorization (PDF) is as follows:

  1. Submit a medication prior authorization request to the PerformRx Prior Authorization team by fax at 1-855-829-2871. For any questions, call PerformRx at 1-855-371-3963.
  2. The HCPCS code that corresponds to the medication request should be included in the request. If the HCPCS code is a miscellaneous code, the National Drug Code (NDC) number must also be included on the request.

In Lieu of Services (ILOS)

Prestige Health Choice has received approval from AHCA to offer care ILOS for members when clinically appropriate. For example, skilled nursing facility services may be offered in place of inpatient care, a Medicaid-covered service.

A provider can determine that a member’s case may be appropriate for a skilled nursing facility, and have the skilled nursing facility submit a request for authorization. Alternatively, the plan may review a continued inpatient stay and recognize that the member is more appropriately suited for a skilled nursing facility.

When submitting a request:

  • Prestige Health Choice will evaluate and determine if a case qualifies for authorization of “in lieu of” skilled nursing facility services.
  • Members must agree in writing to receive the “in lieu of” service before proceeding. Providers need to have the member sign the In Lieu of Service Agreement form (PDF) acknowledging their acceptance of the skilled nursing facility service.
  • The inpatient facility should fax the signed In Lieu of Service Agreement form (PDF) to Prestige Health Choice’s Utilization Management (UM) department at 1-855-236-9293 to be placed in the member’s file for reference.
  • Prestige Health Choice will then provide authorization. An authorization letter will be sent.
  • The inpatient facility should notify the member that nursing facility services have been approved and begin the transfer process.

If you have any questions about ILOS, please contact the UM department directly at 1-855-371-8074.

Pregnancy notification and OB global authorization:

  • All OB care requires a global OB notification and authorization for OB providers to receive proper and expedient payment. Once approved, this authorization includes three OB ultrasounds, labor checks with place of service, all regularly scheduled prenatal visits, and all post-delivery follow-up appointments. In addition, for high-risk pregnancies, unlimited ultrasounds are allowed if they are provided by network maternal and fetal medicine specialists.
  • This authorization initiates Prestige Health Choice Care Management follow-up from a team that works closely with pregnant members. The Care Management program has been developed specifically to help ensure these members keep up with all prenatal and follow-up visits.
  • The pregnancy notification and global OB care authorization form can be faxed to Bright Start® maternity management at 1-855-358-5852.

Prior authorization forms

Pharmacy prior authorization forms