Services Requiring Prior Authorization
Prior authorization is not a guarantee of payment for the service(s) authorized. Keystone First reserves the right to adjust any payment made following a review of the medical record and determination of medical necessity of the services provided.
Important payment notice
Please note that reimbursement for all rendering network providers subject to the ordering/referring/prescribing (ORP) requirement for an approved authorization is determined by satisfying the mandatory requirement to have a valid Pennsylvania Medical Assistance (MA) Provider ID. Claims submitted by rendering network providers that are subject to the ORP requirement will be denied when billed with the NPI of an ORP provider that is not enrolled in MA.
To check the MA enrollment status of the practitioner ordering, referring, or prescribing the service you are providing, visit the DHS provider look-up portal.
Members with Medicare coverage may go to Medicare Health Care Providers of choice for Medicare covered services, whether or not the Medicare Health Care Provider has complied with Keystone First’s Prior Authorization requirements. Keystone First’s policies and procedures must be followed for Non-Covered Medicare services.
The following is a list of services requiring prior authorization review for medical necessity and place of service.
- All elective (scheduled) inpatient hospital admissions, medical and surgical including rehabilitation
- All elective transplant evaluations and procedures
- Elective/non-emergent Air Ambulance Transportation
- All elective transfers for inpatient and/or outpatient services between acute care facilities
- Skilled Nursing facility admission 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 of lesser intensity than that received in a hospital, not to include long term care placements
- Gastroenterology services (codes 91110 and 91111 only)
- Bariatric surgery
- Pain management services performed in a short procedure unit (SPU) or ambulatory surgery unit (either hospital-based or free-standing) and pain management services not on the Medical Assistance fee schedule performed in a physician’s office.
- Cosmetic procedures, regardless of treatment setting, to include, but not limited to the following: reduction mammoplasty, gastroplasty, ligation and stripping of veins, and rhinoplasty
- 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
- Chiropractic services after the initial visit
- Home Health Services by a network provider
- Prior authorization is not required for up to 6 home visits per modality per calendar year including: skilled nursing visits by a RN or LPN; Home Health Aide visits; Physical Therapy; Occupational Therapy and Speech Therapy
- The duration of services may not exceed a 60 day period. The member must be re-evaluated every 60 days
- All Shiftcare/Private Duty Nursing services, including services performed at a medical daycare or Prescribed Pediatric Extended Care Center (PPECC)
- Home Sleep Study
- Purchase of all items in excess of $750
- DME monthly rental items regardless of the per month cost/charge
- The purchase of all wheelchairs (motorized and manual) and all wheelchair items (components) regardless of cost per item
- The rental of all wheelchairs (motorized and manual) and all wheelchair items (components) regardless of cost per item
- Prior authorization is required for members over the age of 21
- Prior authorization is required when the request is in excess of $350/month for members under the age of 21
- Any request in excess of 300 a month for diapers or pull-ups or a combination of both.
- Requests for brand specific diapers.
- All requests for diapers supplied by a DME provider, other than J&B Medical Supply, Bright Medical Supply, King of Prussia Pharmacy, or Matts Pharmacy & Medical Supply (refer to the Durable Medical Equipment section of provider manual for complete details)
- Home Oxygen Therapy
- All requests for oxygen and oxygen equipment require authorization. Initial authorizations are for 6 months and reauthorizations require an updated prescription with current oxygen saturation level (refer to the Durable Medical Equipment section for complete requirements and details).
- Member under 21 years of age
- Member approved for services at a PPECC/Medical Daycare
- Member requires intermittent or continuous oxygen, ventilator support and/or critical physiologic monitoring or critical medication(s) during transport requiring ambulance level of care
- There are no existing mechanisms for caregivers to transport the member
- Request for ambulance services are prior authorized along with initial request for PPECC/Medical Daycare services, with each re-authorization of Medical Daycare services, and/or when there is a change in level of care regarding oxygen, ventilator support and/or specific medical treatment during transport
Rapid Response Transportation Department will be notified with each ambulance approval to initiate and/or continue ambulance transport services
- Positron Emission Tomography (PET)
- Magnetic Resonance Imaging (MRI)/Magnetic Resonance Angiography (MRA)
- Nuclear Cardiology/MPI
- Computed Axial Tomography (CT/CTA/CCTA)
Emergency room, Observation Care and inpatient imaging procedures do not require Prior Authorization.
*Prior authorization is not a guarantee of payment for the service(s) authorized. Keystone First reserves the right to adjust any payment made following a review of the medical record and determination of medical necessity of the services provided.