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Prior Authorization

Prior authorization is required for all referrals to 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:

Services that require Prior Authorization by Keystone First VIP Choice

  • Elective/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/newborn deliveries exceeding forty eight (48) hours after vaginal delivery and ninety six (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 home or outpatient setting, after the first visit per therapy discipline/type.
    • Cardiac and pulmonary rehabilitation.
  • Transplants, including transplant evaluations.
  • All DME rentals and rent to purchase items.
  • DME/medical supply/prosthetic device purchases
    • Purchase of all items in excess of $500 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.
  • Hyperbaric oxygen.
  • Surgery (for sleep apnea/uvulopalatopharyngoplasty (UPPP).
  • Religious non-medical health care institutions (RNHCI).
  • Medications: 17-P and 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 by Keystone First VIP Choice.
  • 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.
  • Cochlear implantation.
  • Gastric bypass/vertical band gastroplasty.
  • Hysterectomy.
  • Pain management – external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation and injections/nerve blocks.
  • Radiology outpatient services:
    • CT scan.
    • PET scan.
    • MRI.
    • MRA.
    • MRS.
    • SPECT scan.
    • Nuclear cardiac imaging.
  • All miscellaneous/unlisted or not otherwise specified codes.
  • All services that may be considered experimental and/or investigational.

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