Some services and medications need to be approved as “medically necessary” by Keystone First before your primary care provider (PCP) or other health care provider can help you to get these services. This process is called “prior authorization.”
Prior authorization process
- Your PCP or other health care provider must give Keystone First information to show that the service or medication is medically necessary.
- Keystone First nurses review the medical information. The nurses use clinical guidelines approved by the Department of Human Services to see if the service or medication is medically necessary.
- If the request cannot be approved by a Keystone First nurse, a Keystone First doctor will review the request.
- If the request is approved, we will let you and your health care provider know it was approved.
- If the request is not approved, a letter will be sent to you and your health care provider telling you the reason for the decision.
- If you disagree with the decision, you may file a complaint or grievance and/or request a Fair Hearing. See complaints, grievances and fair hearings for more information.
- You may also call Member Services for help in filing a complaint, grievance and/or fair hearing.
Services that need prior authorization
- All elective transfers for inpatient and/or outpatient services between acute care facilities.
- Skilled Nursing Facility admissions for alternate levels of care in a facility, either free-standing or part of a hospital, that accepts patients in need of skilled level rehabilitation and/or medical care that is not necessary to be delivered in a hospital. This does not include Long Term Care.
- Services or durable medical equipment (DME) received from providers or hospitals not in the Keystone First network (except for tobacco cessation counseling sessions, emergency services, family planning services, and any Medicare-covered services from a Medicare provider if you have Medicare coverage).
- Elective (non-emergency) admission to a hospital.
- Some medical or surgical procedures performed in a short procedure unit (SPU) or ambulatory surgical unit (ASU), either hospital-based or free-standing, including, but not limited to, the following:
- Steroid injections or blocks administered for pain management.
- Obesity surgery.
- Binding or removing veins.
- All non-emergency plastic or cosmetic procedures (other than those immediately following traumatic injury) including, but not limited to, the following:
- Plastic surgery for eyelids.
- Breast reduction.
- Plastic surgery of the nose.
- Elective termination of pregnancy.
- Admission to a nursing or rehabilitation facility.
- Outpatient Therapy Services (physical, occupational, speech)
Prior Authorization is not required for an evaluation and up to 24 visits per discipline within a calendar year.
Prior Authorization is required for services exceeding 24 visits per discipline within a calendar year.
- Cardiac and pulmonary rehabilitation services.
- Home health services, after 18 visits for each service, including skilled nursing visits; home health aide visits; and physical, occupational, and speech therapy, per calendar year. The member must be re-evaluated every 60 days.
- All shift care/private duty nursing services (including home health aide).
- All DME rentals regardless of the per month cost/charge.
- All wheelchair rentals (motorized and manual) and all wheelchair items.
- All wheelchair purchases (motorized and manual) and all wheelchair items (components) regardless of cost per item.
- All DME purchases that cost more than $750.
- All DME Home Accessibility Items.
- Tube feedings and nutritional supplements (enterals)
- When the member is age 21 and over.
- Diapers and/or pull-up diapers for members 3 years of age or older*, when medically necessary, when requesting:
- More than 300 generic diapers and/or pull-up diapers per month.
- Brand-specific diapers.
- Diapers supplied by a non-preferred DME provider.
- Any service/product not covered by the Medical Assistance program.
- Some outpatient diagnostic tests and procedures.
- Chiropractic services with a Keystone First network provider after the 24th visit if the member is under the age of 18.
- Inpatient hospice services.
- Some specialty dental services.
- PET and CT scans, MRI, MRA, and nuclear cardiology.
- Prescribed pediatric extended care center (PPECC) and medical day care.
- Ambulance transportation to and from prescribed extended care center and medical day care.
- Some formulary prescription drugs, all non-formulary prescription drugs, some over-the-counter (OTC) non-prescription drugs, and some DME supplies obtained through a Keystone First network pharmacy (e.g., glucometers).
- All transplant evaluations and consultations.
- Elective/non-emergent air ambulance transportation.
- Genetic laboratory testing.
*Diapers and/or pull-up diapers are not a covered service for members under the age of 3. Please see the Services That Are Not Covered section in the member handbook for more information or see Benefit limits and services not covered.
As a Keystone First member, you are not responsible to pay for medically necessary, covered services. You may, however, be responsible for a copay.
You may have to pay when:
- A service is provided without prior authorization when prior authorization is required.
- A service is provided by a provider who is not in the Keystone First network and prior authorization was not given to see this provider (except for emergency services; family planning services; and any Medicare-covered services from a Medicare provider if you have Medicare coverage).
- The service provided is not covered by Keystone First and your provider told you that it is not covered before you received the service.