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8.6.18 Outpatient Prior Authorization Process
The following outpatient procedures require prior authorization:
• All laser surgeries
•CT
•CTA
•MRI
•MRA
•pH probe tests
•Some endoscopic procedures
•Some podiatry procedures
•Some surgical procedures
Prior authorization for clients with retroactive eligibility must be obtained by the PCCM provider within 95 days of the add date and before claims submission.
Refer to: Subsection 3.2.5, "Authorization Requirements for CT, CTA, MRI, fMRI, MRA, PET, and Cardiac Nuclear Imaging Services" in the Radiology and Laboratory Services Handbook (Vol. 2, Provider Handbooks) for more information about MRI/MRA and CT/CTA authorizations.
The following outpatient procedures do not require prior authorization:
•Anesthesia services (type of service 7)
•Surgeries performed on an outpatient emergent basis (retrospective authorization must occur for claims payment)
•Application or removal of casts, splints, or strapping (excluding podiatry office procedures and services)
•Burns-local treatment (does not include skin grafts or long-term wound care)
•Catheterization of blood vessels (excluding heart catheterizations) for diagnosis or therapy (includes venous access, puncture of shunt, etc.)
•Cholecystectomy
•Circumcision, newborn and for phimosis (20 years of age and younger)
•Fractures or dislocations (closed or open treatment)
•Incision and drainage of abscesses
•Injection procedures for radiology or in conjunction with surgical procedures
•Intubation or tracheostomy tube changes
•Polysomnography
•Removal of foreign bodies
•Insertion or removal of pressure equalization tubes (myringotomy and tympanostomy)
•Repair of lacerations or wounds (includes the eye)
•Replacement of gastrostomy tubes
•Replantation of digits
•Sterilization procedures (male and female)
•Urodynamics
•Esophageal manometry
•Ultrasounds
•Holter monitors
•Tympanostomy
•Tonsillectomy for clients who are 11 years of age and younger
•Adenoidectomy for clients who are 11 years of age and younger
•Bronchoscopy
•Sigmoidoscopy
•Proctosigmoidoscopy
•Permanent removal of nail or nail matrix
•Colonoscopy (except with endoscopic ultrasound exam or fine needle biopsy)
•Esophageal Endoscopy (except for ablation procedures)
•Appendectomy for ruptured appendix or incidental removal
•Hernia repair (except initial repair)
•Upper GI Endoscopy (except for drainage of psuedocyst or placement of gastrostomy tube)
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