Service Name Prior Auth Reqd? PA Form Notification Reqd? Notify. Form Threshold Product List. Yes, notification within 24 hours.

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1 *Prior authorization confirms medical necessity only and does not guarantee payment. *Payment is determined at the time the claim is received and is subject to health plan exclusions and out-of-network benefit limitations. Plan coverage must be in effect for the member at the time the service(s) is rendered. *Service considered experimental or investigational must be approved by Medicare to be a covered service. *Thresholds stating per year and per calendar year *Services not listed on the grid do not require prior authorization Service Name Prior Auth Reqd? PA tification Reqd? tify. Threshold Product List ACUPUNCTURE Acupuncture is covered for chronic pain. Chronic pain is defined as pain with duration of at least six consecutive months., after threshold's met Authorization Request Medical Surgical Services 40 units per year (unit=15 min) CHEMICAL DEPENDENCY SERVICES Detox - Inpatient Assessors - CD Request Worksheet; Full Rule 25 Treating Facility - (both Input and Oupt treatment) - CD Admission for all Levels of Care/ SCHA CD Complexities Grid, notification within 24 hours. Assessors - CD Request Worksheet Detox - Outpatient t a covered benefit through SCHA Hospital-based inpatient residential program Assessors - CD Request Worksheet; Full Rule 25 Treating Facility - (both Input and Oupt treatment) - CD Admission for all Levels of Care/ SCHA CD Complexities Grid (at time and if complexity changes); Rule 25 & Placement Summary when request continued stay Medication Assisted Treatment (including Suboxone, Methadone, and injectable) Assessors- CD Request Worksheet; Full Rule 25 Treating Facility- (both Input and Outpt treatment) - CD Admission for all Levels of Care/SCHA CD Complexities Grid (at time and if complexity changes); Minnesota Outpt MH/CD Authorization; Rule 25 & Placement Summary when request continued stay Updated: 7/31/2013 1

2 Service Name Prior Auth Reqd? PA tification Reqd? tify. Threshold Product List n-hospital based inpatient residential program (Facilities licensed to provide room and board services only) Low, Moderate, High Intensity n-hospital based inpatient residential program (Residentially licensed chemical dependency provider, eg Rule 31) Low, Moderate, High Intensity Assessors - CD Request Worksheet; Full Rule 25 Treating Facility - (both Input and Outpt treatment) - CD Admission for all Levels of Care/SHCA CD Complexities grid (at time and if complexity changes); Rule 25 & Placement Summary when request continued stay Assessors - CD Request Worksheet; Full Rule 25 Treating Facility - (both Input and Outpt treatment) - CD Admission for all Levels of Care/SHCA CD Complexities grid (at time and if complexity changes); Rule 25 & Placement Summary when request continued stay Outpatient Treatment Assessors - CD Request Worksheet; Full Rule 25 Treating Facility - (both Input and Outpt treatment) - CD Admission for all Levels of Care/SHCA CD Complexities grid (at time and if complexity changes); Rule 25 & Placement Summary when request continued stay Rule 25, to request CD placement DURABLE MEDICAL EQUIPMENT AND RELATED SUPPLIES Government CD Request Worksheet, FULL Rule 25 Apnea monitors Baclofen pumps Communication devices Authorization Request Medical Surgical Services Continuous Glucose Monitoring systems Authorization Request Medical Surgical Services Custom wheelchairs (power) and Power operated vehicle (POV) Authorization Request Medical Surgical Services te: authorization is needed for repairs or items needed to maintain the function of the POV is under $750. This includes batteries, battery chargers, tires, arm rests, general use cushions, and anti-tip devices. Equipment greater or equal to $750 or any rental item rented for greater than 4 months. (Rental is paid up to purchase price.) Authorization Request Medical Surgical Services Insulin pumps Authorization Request Medical Surgical Services Updated: 7/31/2013 2

3 Service Name Prior Auth Reqd? PA tification Reqd? tify. Threshold Product List Orthotics or Prosthetics over $750 Authorization Request Medical Surgical Services Oxygen, excluding oxygen supplies, nebulizers, BI PAP and ventilators Authorization Request Medical Surgical Services PMAP and MnCare, for initial use only Authorization Request Medical Surgical Services MSC+, MSHO, AbilityCare, SNBC with Medicare, SNBC Medicaid Only Oxygen, CPAP, after 4 months of use. Authorization Request Medical Surgical Services Positioning seats Authorization Request Medical Surgical Services Specialty hospital beds Authorization Request Medical Surgical Services Specialty pressure mattress Unlisted code E1399 over $500 (Misc. DME) Unlisted code K0108 over $500 (Misc. wheelchair accessories) Authorization Request Medical Surgical Services Authorization Request Medical Surgical Services Authorization Request Medical Surgical Services Vest percussors Authorization Request Medical Surgical Services HEALTH AND SAFETY EQUIPMENT AND SERVICES Health and Safety Equipment and Services HEARING AID Hearing Aide, new and replacement. Care Coordinator submits PA More than 2 replacements in 5 years requires PA SCC Health & Safety Request v.1 $300 per year MSHO Authorization Request Medical Surgical Services 2 replacements in a 5- year period Updated: 7/31/2013 3

4 Service Name Prior Auth Reqd? PA tification Reqd? tify. Threshold Product List HOME HEALTH SERVICES - MEDICARE Skilled nursing care, Therapy (PT, OT, ST); Medical social services; and Medical Supplies CMS-485 or Physician's Order for the skilled services MSHO and AbilityCare HOME CARE SERVICES - MEDICAL ASSISTANCE AND DD, CAC, CADI, BI WAIVER Home Health Aide, auth must be case mgr DHS-5841 Recommendation for Authorization of MA Home Care Services Member must have a DD, CAC, CADI, BI waiver. PMAP, MSC+, MSHO, AbilityCare, SNBC with Medicare, SNBC with Medicaid Only Personal Care Assistant (PCA), auth must be case mgr DHS-5841 Recommendation for Authorization of MA Home Care Services Member must have a DD, CAC, CADI, BI waiver. PMAP, MSC+, MSHO Private Duty Nursing, auth must be case mgr DHS-5841 Recommendation for Authorization of MA Home Care Services Member must have a DD, CAC, CADI, BI waiver. PMAP, MSC+, MSHO Skilled Nurse Visits, auth must be case mgr. DHS-5841 Recommendation for Authorization of MA Home Care Services Member must have a DD, CAC, CADI, BI waiver. PMAP, MSC+, MSHO, AbilityCare, SNBC with Medicare, SNBC with Medicaid Only HOME CARE SERVICES - MEDICAL ASSISTANCE AND ELDERLY WAIVER Home Health Aide, auth must be case mgr. SCHA Waiver tification must be submitted by the member's care coordinator to SCHA. MSC+, MSHO, Member must have EW Personal Care Assistant (PCA), auth must be case mgr. SCHA Waiver tification must be submitted by the member's care coordinator to SCHA. MSC+, MSHO, Member must have EW Private Duty Nursing, auth must be case mgr. SCHA Waiver tification must be submitted by the member's care coordinator to SCHA. MSC+, MSHO, Member must have EW Skilled Nurse Visits, auth must be case mgr. SCHA Waiver tification must be submitted by the member's care coordinator to SCHA. HOME CARE SERVICES - MEDICAL ASSISTANCE NON-WAIVER MSC+, MSHO, Member must have EW Home Health Aide Personal Care Assistant (PCA), after the 9th visit per calendar year. Home Care Fax (DHS-4074) or Authorization Request Medical Surgical Services Personal Care Assistance and Service Plan (DHS-3244) PMAP, MSC+, MSHO, AbilityCare, SNBC with Medicare, SNBC with Medicaid Only Member does NOT have a waiver PMAP, MSC+. MSHO- Member does NOT have a waiver Private Duty Nursing MA Private Duty Nursing - (DHS-4071A) PMAP, MSC+. MSHO- Member does NOT have a waiver Skilled Nurse Visits, after the 9th visit per calendar year Home Care Fax (DHS-4074) or Authorization Request Medical Surgical Services PMAP, MSC+, MSHO, AbilityCare, SNBC with Medicare, SNBC with Medicaid Only - Member does NOT have a waiver HOSPICE CARE Updated: 7/31/2013 4

5 Service Name Prior Auth Reqd? PA tification Reqd? tify. Threshold Product List Hospice Care Hospice tification Worksheet HOSPITAL CARE - INPATIENT Continued Stays for More than 2 days Authorization Request Medical Surgical Services - Within 24 hours SCHA requests a discharge notification within 24 hours of discharge. Inpatient tification for both admission and discharge Emergent Medical Hospital Admission - Within 24 hours SCHA requests a discharge notification within 24 hours of discharge. Inpatient tification for both admission and discharge n-emergent Medical Hospital Admission Authorization Request Medical Surgical Services - Within 24 hours SCHA requests a discharge notification within 24 hours of discharge. Inpatient tification for both admission and discharge Swing Bed - Refer to Nursing Home Services on this PA grid MENTAL HEALTH SERVICES ACT (Assertive Community Treatment) Acute Inpatient Mental Health Government tification MH/CD Worksheet - Prior Authorization and tification - Within 24 hours MH/CD Worksheet - Prior Authorization and tification ; See te F Adult Crisis Residential Services, after 5 days., upon admission. Government tification Adult Day Treatment (Behavioral Health Day Treatment - See te E below. Max 15 hrs per week; may not obtain authorization for more day treatment hours in a week; 115 hours per calendar yr without authorization Updated: 7/31/2013 5

6 Service Name Prior Auth Reqd? PA tification Reqd? tify. Threshold Product List ARMHS (Adult Rehabilitative Mental Health Services) met and also if provided concurrently with ACT services.., at the start of care Government tification 1200 Units cumulative, All ARMHS codes combined per year Certified Peer Specialist 300 hrs per calendar year combined total by Level I, II, and peer services in a group setting. Support) Behavioral Health Day Treatment Minimum 2 hrs daily & PMAP Max 3 hrs, may not obtain auth'n for more day treatment hrs in a day; Max 15 hrs/ week; may not obtain auth'n for more day treatment hrs in a week; 150 hrs per calendar yr; request auth'n for additional medically necessary services Support) Family Therapy 26 sessions per year; cumulative for any combination of group therapy PMAP Support) Group Therapy 52 sessions per year cumulative for any combination of group psychotherapy PMAP Support) Multifamily Group 10 sessions per year PMAP Support) Therapy 200 cumulative hours per calendar year (units vary by 30, 45, or 60 minutes) PMAP Support) Skills Training & Development 200 cumulative hours per calendar year for any combination of psychotherapy, skills training, crisis assistance, therapeutic components of preschool program and Mental Health Behavioral Aide services. Updated: 7/31/2013 6

7 Service Name Prior Auth Reqd? PA tification Reqd? tify. Threshold Product List DBT (Dialectic Behavioral Therapy ) - Individual DBT Therapy MH/CD Worksheet - Prior Authorization and tification Up to 26 hours (104 units) per 6 moths (unit=15 min), See note E DBT (Dialectic Behavioral Therapy) Group DBT Skills Training MH/CD Worksheet - Prior Authorization and tification Up to 78 hours (312 units) per 6 month (unit =15 min), See note E Diagnostic Eating Disorders - Inpatient Treatment *Go to n-emergent Medical Hospital Admission Eating Disorders - Outpatient MH/CD Worksheet - Prior Authorization and tification Authorization Request Medical Surgical Services, within 24 hours Inpatient tification MN Universal Outpatient Mental Health/Chemical Dependency Authorization 2 sessions 4 max per year See note D below IMD (Institute of Mental Disease) Intensive Outpatient Mental Health Treatment MH/CD Worksheet - Prior Authorization and tification MH/CD Dependency Admission Worksheet MN Universal Outpatient Mental Health/Chemical Dependency Authorization 10 days per episode IRTS (Intensive Residential Treatment Services) MH/CD Dependency Admission Worksheet 90 days per episode - See te C below MH-TCM (Mental Health Targeted Case Management) MH TCM Eligibility Determination ; DA; Verification of SPMI/SED, within 60 days of completed DA or request for MH-TCM services. Fax to MH TCM Eligibility Determination and supporting documentation Neuropsychological Testing Psychological Testing 7 hours (15 hrs max per person per year) Updated: 7/31/2013 7

8 Service Name Prior Auth Reqd? PA tification Reqd? tify. Threshold Product List Partial Hospitalization Psychological Testing Psychotherapy - Family Psychotherapy - Group MN Universal Outpatient Mental Health/Chemical Dependency Authorization 10 days per episode Psychological Testing 4 hours (8 hours max per person per year) 26 sessions of family psychotherapy per calendar year; 10 sessions of multiple family group psychotherapy per calendar year 52 sessions per calendar year, cumulative. See te G. Psychotherapy - Individual 26 hours per calendar year cumulative. See te G. Rule 5 Children's' Residential Treatment Services MH/CD Dependency Admission Worksheet MH/CD Dependency Admission Worksheet PMAP, MNCare NURSING HOME SERVICES NF - Custodial Care - Within 24 hours SNF - Intensive Service Days Nursing Home Communication - Within 24 hours Nursing Home Communications Nursing Home Communications MSC+, MSHO, AbilityCare, SNBC with Medicare, SNBC with Medicaid Only MSHO, AbilityCare, SNBC with Medicare, SNBC with Medicaid Only SNF or NF - Private Room Nursing Home Communication - Within 24 hours SNF - Skilled Care Days Nursing Home Communication - Within 24 hours Nursing Home Communications Nursing Home Communications MSHO, AbilityCare, SNBC with Medicare, SNBC with Medicaid Only, MSC+ MSHO, AbilityCare Swing Bed - See note K Inpatient tification MSHO, AbilityCare, SNBC with Medicaid Only Updated: 7/31/2013 8

9 Service Name Prior Auth Reqd? PA tification Reqd? tify. Threshold Product List OUT-OF-NETWORK SERVICES Out-of-Network Provider/Service, if services are indicated as needing a PA on the PA Grid PUBLIC HEALTH NURSE VISITS Authorization Request Medical Surgical Services Public Health Nurse Visits REHABILITATION Acute Care Rehab Authorization Request Medical Surgical Services Outpatient Therapies - Physical Therapy, Occupational Therapy, Respiratory Therapy, Speech Therapy - maintenance (custodial) therapies for members over 20 yrs old. SURGERY Circumcision - Routine Circumcisions are not a covered benefit. Authorization Request Medical Surgical Services Miscellaneous - See te A below Authorization Request Medical Surgical Services Oral Surgery, Maxillofacial Surgery, or Uvulopalatopharyngoplast y (UPPP), Alveoplasty Authorization Request Medical Surgical Services Reconstructive procedures and/or potentially cosmetic procedures Spinal Surgeries - Arthrodesis, Lumbar Fusion, or X-Stop TRANSPLANTS - See note B below Authorization Request Medical Surgical Services Authorization Request Medical Surgical Services Transplants, except cornea and kidney Authorization Request Medical Surgical Services for Cornea, for Kidney Inpatient tification Updated: 7/31/2013 9

10 Service Name Prior Auth Reqd? PA tification Reqd? tify. Threshold Product List VISION Lenses with special tints, coatings, or no glare Authorization Request Medical Surgical Services Vision Therapy Authorization Request Medical Surgical Services 1 exam & 1 weekly therapy session per 6 MISCELLANEOUS month period Growth Hormones MN Uniform ulary Exception Medications administered in Physician's office costing greater than or equal to $750. See note J. Authorization Request Medical Surgical Services Updated: 7/31/

11 Service Name Prior Auth Reqd? PA tification Reqd? tify. Threshold Product List Botox See note I. Authorization Request Medical Surgical Services Nutritional Supplements, after the threshold is met Authorization Request Medical Surgical Services 1040 units per month Specialty ula Authorization Request Medical Surgical Services Restricted Recipients, all referrals to a specialist require notification from the Primary Care Clinic Manage Care Referral Authorization Requests: MMSI Health Services Fax: Benefit Plan Provisions: Call Provider Services Verify Member Eligibility and Primary Care Location: Provider Services Center Prime Therapeutics Utilization Management: Fax te A - such as, but not limited to: Implantable ventricular assist systems and artificial hearts, lung volume reduction, vargus ner ve stimulation, deep brain stimulation, varicose vein treatment, bone stimulators te B - such as, but not limited to: Brow Lifts, Panniculectomy, scar excision/revision, reduction mammoplasty or mastoplexy, bariatr ic surgery, subcutaneous injections to change contours, suction lipectomy, tattooing or tattoo removal, septoplasty and rhinoseptoplasty, salabrasions, skin peels te C - Maximum 90 days per episode. Readmission within 15 days counts towards 90 day limit. Request authorization for more than 90 days. Service limitations apply when providing IRTS and other concurrent services. Please see SCHA Mental Health Provider Manual for specifics. te D - Authorization is required to exceed 2 sessions per calendar year, cumulative for and Maximum of 4 sessions per calendar year. Provider cannot bill both and for same recipient - choose one or the other. Interactive complexity add-on may be used with ofr See SCHA Mental Health Provider Manual for specifics. te E - Authorization 1. After threshold; or 2. When receiving concurrent DBT services (regardless of 115hrs was met; or 3. Authoriza tion is required to provide concurrent partial hospitalization or adult day tx and residential crisis stabilization services concurrently. te F - Service limitations apply when providing ACT and other concurrent services. Please see SCHA Mental Health Provider Manual for specifics. te G - Interactive complexity may be used with some psychotherapy codes. Please see SCHS Mental Health Provider Manual for specific s. te H - Do not provide psychotherapy concurrently with interactive psychotherapy. Interactive complexity may be used in certain situa tions. See SCHA Mental Health Provider Manual for specifics. te I - Per DHS Botox cannot be used for the treatment of migraines. te J - Synagis does not require a prior authorization. te K - t a covered benefit for PMAP, MN Care, MSC+. Contact DHS provider services for further assistance. For SNBC members wi th Medicare elsewhere contact Medicare. te L- Ability Care refers to SCHA's dual integreated plan. SCHA covers both Medicare and Medicaid. SNBC with Medicare refers to those members who have only their Medicaid coverage through SCHA and Medicare elsewhere. SNBC Medicaid Only refers to those members who only have Medicaid eligibility and have full Medicaid b enefits through SCHA. If you have a question about a service not listed, call MMSI Provider Services at Benefits are subject to eligibility at the time service is rendered. Authorization s can be found at under Provider Resources tab and then forms Updated: 7/31/