Services that need prior authorization

Some medical services or provider visits require prior authorization. This helps us manage your care and ensure you receive the care you need when it’s medically necessary.

Here are the most common services that require prior authorization. This list is not comprehensive. For specific benefit information and documented confirmation of services requiring prior authorization, contact Member Services.

• Bariatric surgery
• Certain Medical Injectables as stated in our Medical Policies
• Residential mental health and substance use services
• Certain outpatient radiology (e.g., MRI, CT, PET scan)
• Covered oral surgery procedures as stated in our Medical Policies (e.g. Orthognathic Surgery)
• Durable medical equipment (DME): as stated in our medical policies
• Elective hospital inpatient admissions and services
• Gender Affirmation Procedures
• Elective inpatient mental health and substance use services
• Inpatient medical rehabilitation admissions and services

• Long-term acute care hospitalization(LTACH)
• Medical Supplies as stated in our Medical Policies
• Non-emergency air and/or water ambulance transport
• Outpatient hospital or ambulatory surgical services
• Elective surgical care at an ambulatory surgical center, outpatient hospital or a provider's office as stated in our Medical Policies
• Pain management services as stated in our Medical Policies
• Select diagnostic testing as stated in our Medical Policies
• Skilled nursing facility/swing bed
• Sleep studies as stated in our Medical Policies
• Temporomandibular disorders (TMJ) - Surgical services
• Transplant services – (except cornea)