Effective: July 28, Arizona Prior Authorization Requirements Health Net Access, Inc.

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1 Effective: July 28, 2015 Arizona Prior Authorization Requirements Health Net Access, Inc. The following services, procedures and equipment are subject to prior authorization requirements (unless noted as notification required only). When faxing a request, please attach pertinent medical records, treatment plans, test results, and evidence of conservative treatment to support the medical appropriateness of the request. All services are subject to benefit plan coverage limitations, members must be eligible, and medical necessity must exist for any plan benefit to be a covered service irrespective of whether or not prior authorization is required. Providers should refer to Health Net Access prior authorization limitations and exclusions on page 4 for additional information. Unless noted differently, all services listed below require prior authorization from Health Net Access. Refer to page 5 for submission information and prior authorization contacts. INPATIENT SERVICES 1 Acute rehabilitation facility Behavioral health or detoxification effective October 1, 2015 Hospice facility Hospital facility Newborns births (including stillborn and unexpected deaths) within 12 hours of delivery Nursing facility/skilled nursing facility Observation services Urgent/emergent admission OUTPATIENT PROCEDURES, SERVICES OR EQUIPMENT All non-contracting and out-of-state services Ambulance applies to dual eligible members only* includes hospital, psychiatric hospital, subacute facility, and residential treatment center or related bed holds Providers must complete and submit the Newborn Reporting Form, in conjunction with the Health Net prior authorization request, by secure fax to the Health Net Hospital Notification Unit. The Newborn Reporting Form is available in the Forms section of the Provider Library on the Health Net provider website at provider.healthnet.com. Notification required only; contact the Health Net Hospital Notification Unit Notification required only as soon as possible, but no later than 24 hours or by the next business day; contact the Health Net Hospital Notification Unit Applies to non-emergency air or ground transportation *Dual eligible members are members who are eligible and enrolled for coverage through Medicare and Effective October 1, 2015, dual eligible members have Page 1 of 5

2 OUTPATIENT PROCEDURES, SERVICES OR EQUIPMENT, CONTINUED Back surgery Includes laminotomy, diskectomy, vertebroplasty, and nucleoplasty Bariatric-related services Blepharoplasty Breast implants removal Breast reconstruction Breast reduction and augmentation Cardiac and pulmonary rehabilitation therapy Circumcision Cleft palate reconstructive surgery, including dental and orthodontic services Clinical trials Cosmetic services, evaluation and procedure Custom orthotics Applies to members under age 21 Dental Contact Dental Benefit Providers Dermatology (in-office procedures) Including: chemical exfoliation and electrolysis ( ) dermabrasion/chemical peel ( ) laser treatment ( ) skin injections and implants ( ) Electroconvulsive therapy (ECT) effective October 1, 2015 Applies to dual eligible members only* Genetic testing Covered only to differentiate between treatment options Durable medical equipment (DME) Applies to items exceeding $2,500 in billed charges Enteral/parenteral services and supplies Experimental/investigational services and new technologies Home health services Applies to the following services: home uterine monitoring nursing occupational therapy Hospice/palliative care Hyperbaric oxygen therapy Incontinence briefs Applies to members ages 3 to 20 Intensity modulated radiation therapy (IMRT) LifeVest Includes, but is not limited to, those listed in the Investigational Procedures List located on the Health Net provider website at provider.healthnet.com > View our Medical Policies > Investigational Procedure List. physical therapy speech therapy tocolytic services *Dual eligible members are members who are eligible and enrolled for coverage through Medicare and Effective October 1, 2015, dual eligible members have Effective: July 28, 2015 Page 2 of 5

3 OUTPATIENT PROCEDURES, SERVICES OR EQUIPMENT, CONTINUED Maternity Neuro or spinal cord stimulators Neuropsych testing Orthognathic procedures (including TMJ treatment) Outpatient diagnostic procedures Notification required only at the time of first prenatal visit. Providers are required to identify risk factors by completing a comprehensive tool that covers psychosocial, nutritional, medical, and educational factors (such as the American Congress of Obstetricians and Gynecologists (ACOG) or Mutual Insurance Company of Arizona (MICA) assessment tools), in conjunction with the Health Net Request for Prior Authorization form. Health Net Request for Prior Authorization form available in the Forms section of the Provider Library on the Health Net provider website at provider.healthnet.com. Contact evicore healthcare for the following procedures: computed tomography (CT) magnetic resonance angiography (MRA) scans magnetic resonance imaging (MRI) scans nuclear cardiac imaging procedures positron emission tomography (PET) Perinatology referral and care Notification required only Posterior tibial neuro stimulation/pelvic floor stimulation Pregnancy termination Prosthetics Applies to items exceeding $2,500 in billed charges Proton beam therapy Psychological testing effective October 1, 2015 Applies to dual eligible members only* Rhinoplasty Septoplasty Stereotactic radiosurgery and stereotactic body radiotherapy (SBRT) Sterilization Transplant-related services, including evaluation Treatment of varicose veins Uvulopalatopharyngoplasty (UPPP) and laser-assisted UPPP X-Stop *Dual eligible members are members who are eligible and enrolled for coverage through Medicare and Effective October 1, 2015, dual eligible members have Effective: July 28, 2015 Page 3 of 5

4 OUTPATIENT PHARMACEUTICALS (SUBMITTED UNDER MEDICAL BENEFIT CLAIMS) Hemophilia factors Self-injectables Actemra Intravenous Remodulin Aldurazyme immunoglobulin Rituxan (nononcology Aralast (IVIG) only) Aranesp Krystexxa Simponi Aria Benlysta Lucentis Soliris Botox Lumizyme Stelara Ceredase Makena Synagis Cerezyme Myobloc Tysabri Cinryze Myozyme Ventavis Dysport Naglazyme Vpriv Entyvio * Nplate Xeomin Fabrazyme Orencia Xiaflex Flolan Prolastin Xolair Glassia Provenge Zemaira Ilaris Remicade Prior Authorization Limitations and Exclusions Listed below are prior authorization limitations and exclusions, and sensitive, confidential or other services that do not require prior authorization for Health Net Access members. Authorizations for Children s Rehabilitation Services (CRS)-eligible conditions for members under age 21 and enrolled in CRS require prior authorization from CRS. Contact CRS at or by at Routine laboratory services must be performed at participating facilities Authorization requests for behavioral health and substance abuse services for children, individuals with serious mental illness (SMI) and those who are not dually eligible for Medicare and Medicaid must be referred to RBHAs/TRBHAs. If coordination assistance with RBHAs/TRBHAs is needed, contact the Health Net Access Member Services Department. For dual eligible non-smi members, behavioral health and substance abuse services are excluded. Emergency room (ER) services after stabilization of an emergency medical condition or when the medical screening exam (MSE) does not demonstrate an emergency medical condition are subject to review by Health Net and may not be paid *Dual eligible members are members who are eligible and enrolled for coverage through Medicare and Effective October 1, 2015, dual eligible members have Effective: July 28, 2015 Page 4 of 5

5 Prior Authorization Contacts Listed below are contact numbers for requesting prior authorization via telephone and fax. Also included is contact information for commonly requested Health Net and other departments. CONTACT INFORMATION Prior authorization request ; fax: Health Net Prior Authorization Request available in the Forms section of the Provider Library on the Health Net provider website at provider.healthnet.com Behavioral health Coordinated by Mercy Maricopa Integrated Care: or (TDD/TTY: 711) Behavioral health (inpatient behavioral health or detoxification; ; fax: ECT; and psychological testing) for dual eligible members only* Dental Benefit Providers Health Net Dental Dental Benefit Providers AZ Medicaid PO Box 306 Milwaukee, WI Eligibility and benefits provider.healthnet.com or Health Net Access Member Services Department (TTD/TTY: (888) ) Health Net Hospital Notification Unit ; fax: After hours and weekends: Medicaid general information Arizona Health Care Cost Containment System (AHCCCS) Health Net Pharmaceutical Services (HNPS) ; fax: evicore healthcare for listed outpatient diagnostic procedures ; fax: ; *Dual eligible members are members who are eligible and enrolled for coverage through Medicare and Effective October 1, 2015, dual eligible members have Effective: July 28, 2015 Page 5 of 5

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