WVP Health Authority - MPCHP Referral/Preauthorization Grid

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1 Referral Preauthorization Contacts Members A thru Em: Option 2 Option 1 Members En thru Led Option 2 Option 2 Members Lee thru Roa: Option 2 Option 3 Members Rob thru Z: Option 2 Option 4 SERVICE OR PROCEDURE Pre Auth Referral PREVENTIVE AND WELLNESS SERVICES Immunizations - Excludes Synagis which requires a PA Cholesterol Testing Hepatitis A Vaccine or B Vaccine Flu Shots Pneumonia Vaccine Preventive Exams (includes Pap & Pelvic) Limited benefit Mammogram Pap Smears Colorectal Exams Fecal Occult Blood Sigmoidoscopy Diabetes Education Limited benefit Prostate Cancer Screening PHYSICIAN SERVICES Office Visits-Primary Care Provider Consultation with Specialist *** See updated Policy on -See policy *** exceptions Physician visits during hospitalization Follow Up visit after ER (with specialist) PT, OT ST Evaluations ***See updated Policy on - within policy limits Outpatient Therapies i.e. PT, OT, ST. Allergy Test Treatment -MPCHP benefit - Exception Only OUTPATIENT HOSPITAL SERVICES WVP Health Authority - MPCHP Referral/Preauthorization Grid MPCHP

2 Surgical Services Ambulatory clinic services(steps, SHAPES, SHOTS, STARS etc) Plasmapheresis Pulmonary& Cardiac Rehabilitation Pain Management Program INPATIENT HOSPITAL SERVICES Inpatient Stays-UM notification w/in 24 hours Inpatient Rehab Center Intermediate Care Facility Therapies Skilled Nursing Facility Stays Home Health Care Services Hospice MPCHP* MENTAL HEALTH AND CHEMICAL DEPENDENCY Inpatient Mental Health Treatment- Call Behavioral Care Network at Inpatient Chemical Dependency - 3 day medical detox only Outpatient Mental Health - Call Behavioral Care Network at Outpatient Chemical Dependency - Members can self refer to contracted providers EMERGENCY SERVICES Emergency Room, Urgent Care (Processed after receipt of claim) n emergency out of area services COVERAGE FOR ADDITIONAL SERVICES AND SUPPLIES Durable Medical Equipment (Certificate of Medical Necessity) Orthotics/Prosthetics Chiropractic Services: Coverage dependent on medical review VISION SERVICES Medical Eye Problems Retinal Exam for Diabetics Routine Visual Exams: Subject to benefit Eyeglasses: Subject to benefit Vision Therapy Glasses after Cataract Surgery - Subject to benefit

3 HEARING SERVICES Routine Hearing Exams: Subject to benefit Hearing Aid Repairs Hearing Aids: Subject to benefit (OHP only) COMMON DIAGNOSTIC PROCEDURES- All diagnostic procedures require a referral to the ordering physician with a diagnostic option, and PA if indicated. 2 week to 30 day cardiac event monitor 93012, 93014, 93228, 93229, , 93237, hr ECG monitor and real time analysis CPT hour PH Probe with admission Amniocentesis (may need referral to specialist) Angiogram/Cardiac Catheterization Arthocentesis/ Joint aspiration Barium Enema Biopsy - Needle or Ultrasound guided Biopsy - Skin Bone Scan Bronchoscopy w/bx or washing Cardiac echo Cardio Stress w/echo Cardioversion Carotid Ultrasound Colonoscopy PA required ONLY if less than 50 years of age -over 50 Colposcopy CT Scan-Spiral, CTA, 3-D Rendering Cystoscopy D&C, D&E Dexascan Discogram Dopplers EEG (For video EEG admit 24 hrs. PA is required) EGD (Esophagogastroduodenoscopy and upper endoscopy) EGD with Botox EMG/NCS (Electromyography/nerve conduction study)

4 Hepatobiliary Imaging Hysteroscopy Hysteroscopy with Ablation(58563) IVP (Intravenous Pyelogram) Leep Cone (57460) Lumbar Puncture Maternity Ultrasound, medically necessary MRI Scan MRA Scan Myelogram n Stress test - Prenatal Birth Control(all) Insertion/Removal Nuclear Med Scans, URIA Breath Test Pacemaker Checks ( ) Cardiac SPECT Scans Pet Scans, META Scans, SPECT Scans, MUGA scans Proton Beam Treatment Pulmonary Function Test Sleep Studies (auth required for initial consult w/1 f/u) UGI Ultrasounds, VCUG UVA / UVB treatments Zio Patch & X-Rays SURGICAL PROCEDURES- All surgical procedures require a referral to the performing physician with a surgery option, and PA if indicated. Any procedure requiring early admit or extended stay(longer then customary) Co-Surgeons Hysterectomies In patient surgery MOHS Outpatient Dental Surgery- Anesthesia and Facility Only Out patient surgery

5 PICC line/porta cath Placement Shunt Placement/Replacement Surgery Assist Sterilization (with valid consent form)includes Tubal, Essure, Adina Vasectomy (with valid consent form) OTHER Joint Injections - Synvisc, Hyalgen, Supartz (OHP Exclusion) Excluded Excluded Chemotherapy (Administered in Office) Epidural steroid injections Facet Injections- t covered by OHP Trigger Point Injections t covered by OHP Radio Frequency Nerve Ablation Dialysis performed in outpatient hospital and dialysis center Genetic Testing-There is a reasonable expectation that the results of genetic testing will alter the patient's treatment plan. Transplants Implanted patient-activated cardiac event recorder CPT Investigational/Experimental Infertility Procedures Bariatric Surgery Plastic, Reconstructive and Cosmetic Procedures Clinical Trials- OHP Exclusion Excluded Excluded

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