COMPREHENSIVE PRIOR AUTHORIZATION LISTS NJ FAMILYCARE/MEDICAID & DUAL COMPLETE HMO SNP PRODUCTS EFFECTIVE 7/1/13

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1 TO ALL HEALTHCARE PROFESSIONALS: COMPREHENSIVE PRIOR AUTHORIZATION LISTS NJ FAMILYCARE/MEDICAID & DUAL COMPLETE HMO SNP PRODUCTS EFFECTIVE 7/1/13 BEFORE SEEKING PRIOR AUTHORIZATION, PLEASE VERIFY MEMBER BENEFITS AS ELIGIBLE SERVICES MAY VARY WITHIN THE DIFFERENT PLANS TYPES. TO CHECK MEMBER ELIGIBILITY PLEASE CALL OUR PROVIDER CALL CENTER AT: OR ONLINE AT UNITEDHEALTHCAREONLINE.COM. NOTE: ALL OUT-OF-NETWORK (OON) SERVICES REQUIRE PRIOR AUTHORIZATION NJ FAMILYCARE/MEDICAID PRIOR AUTHORIZATION LIST Medicaid Prior Authorization Services Ablative Procedures for Venous Insufficiency and Varicose Veins Abortions - No Prior Authorization Required Requires consent form at time of claim submission Ambulance Services - Non emergency transportations Bariatric Surgery Blepharoplasty and Brow Ptosis Repair Breast Reduction 1

2 Medicaid Prior Authorization Services Cardiology Program includes the following: Diagnostic Heart Catheterization (Effective 9/1/2013) Telephone: or Fax: Stress Echocardiography (Effective 9/1/2013) Telephone: or Fax: Transthoracic Echocardiography (Effective 9/1/2013) Telephone: or Fax: Cardiac Implantable Devices (Effective 9/1/2013) Telephone: or Fax: Chiropractic services Cosmetic Surgery UnitedHealthcare Dental: Prior Authorization must be in writing; providers can submit authorization requests via paper, or through the online web portal: Dental - Comprehensive Services United Healthcare Community Plan Attn: Prior Authorizations P.O. Box 2076 Milwaukee, WI Durable Medical Equipment (DME) >$500 Power mobility devices and all wheelchair accessories regardless of dollar amount Providers may call to discuss their concerns prior to submitting a Prior Authorization at: Drug - Acthar HP Drug - Botulinum Toxins 2

3 Medicaid Prior Authorization Services Drug - IVIG Drug - Makena Drug - Synagis Pharmacy Prior Authorization: Specialty Pharmacy Prior Authorization: or Fax: Drug - Xolair Pharmacy Prior Authorization: Specialty Pharmacy Prior Authorization: or Fax: Elective Inpatient Admissions Gynecomastia Home Health Care - All services in the home including but not limited to: Home Infusion Nurse Aide Private duty nursing PT/OT/ST Skilled nursing Social worker Hospice Services Medical Day Care Services Telephone: Fax#: or Nursing facilities, long-term acute care, skilled nursing facility, and extended care Panniculectomy and Body Contouring Procedures 3

4 Medicaid Prior Authorization Services Pediatric Day Care Services Telephone: Fax#: or Personal Care Services Telephone: Fax#: or Private Duty Nursing (authorized for children up to age 21) Radiology Program includes the following: Magnetic Resonance Image (MRI) Telephone: or Fax: Magnetic Resonance Angiography (MRA) Telephone: or Fax: Computerized Axial Tomography (CT) Telephone: or Fax: Positron-Emission Tomography (PET) Telephone: or Fax: Nuclear Medicine Telephone: or Fax: Nuclear Cardiology Telephone: or Fax: Rhinoplasty, Septoplasty and Turbinate Resection Sleep study in the outpatient setting. No authorization required in the home setting Sterilization Procedures - Authorization not required, requires consent form at time of claims submission Hysterectomy Tubal ligation Vasectomy 4

5 Medicaid Prior Authorization Services Therapy/Rehab (OP/Office setting) including: OT - Authorization required after the 12th visit PT - Authorization required after the 12th visit ST - Authorization required after the 12th visit Transplant Services Telephone: or Fax

6 NJ DUAL COMPLETE HMO SNP PRIOR AUTHORIZATION LIST Medicare Prior Authorization Services Bariatric Surgery Bone Growth Stimulator Breast Reconstruction (Non Mastectomy) Capsule Endoscopy Cardiology Program includes the following: Diagnostic Heart Catheterization (Effective 9/1/2013) Telephone: or Fax: Stress Echocardiography (Effective 9/1/2013) Telephone: or Fax: Transthoracic Echocardiography (Effective Telephone: or Fax: /1/2013) Cardiac Implantable Devices (Effective 9/1/2013) Telephone: or Fax: Cochlear & Auditory Implants Cosmetic & Reconstructive UnitedHealthcare Dental: Prior Authorization must be in writing; providers can submit authorization requests via paper, or through the online web portal: Dental - Comprehensive Services United Healthcare Community Plan Attn: Prior Authorizations P.O. Box 2076 Milwaukee, WI Providers may call to discuss their concerns prior to submitting a Prior Authorization at:

7 Medicare Prior Authorization Services Durable Medical Equipment (DME) regardless of dollar amount: Power Mobility Devices, Accessories, Lymphedema Pumps and Pneumatic Compressors Durable Medical Equipment (DME) >$1000 Home Care Home Care - Nutritional Hyperbaric Oxygen Therapy Joint Replacement Muscle Flap Non-Emergency Transportation Orthognathic Orthotics >$1000 Potentially Unproven Services Prosthetics >$1000 Proton Beam Radiology Program includes the following: Magnetic Resonance Image (MRI) Telephone: or Fax: Magnetic Resonance Angiography (MRA) Telephone: or Fax: Computerized Axial Tomography (CT) Telephone: or Fax: Positron-Emission Tomography (PET) Telephone: or Fax: Nuclear Medicine Telephone: or Fax: Nuclear Cardiology Telephone: or Fax:

8 Medicare Prior Authorization Services Septoplasty/Rhinoplasty Sleep Apnea Procedures & Surgeries Spinal Stimulator Spine Surgeries Therapy/Rehab (OP/office setting) including: OT - Authorization required after the 12th visit PT - Authorization required after the 12th visit Telephone: or Fax: ST - Authorization required after the 12th visit Telephone: or Fax: Transplant Services Telephone: or Fax Vein Procedures 8

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