Authorization Guidelines - Group Health Cooperative of Eau Claire

2013 Commercial
Authorization Guidelines
Group Health Cooperative requires that you obtain a prior authorization from our Health Management
department to see out-of-network providers, as well as for inpatient admissions and other specified
services. Authorization for services does not guarantee payment for services. Payment for services is
dependent on medical necessity as well as other non-medical criteria such as the benefits associated
with your specific plan and your eligibility.
Your provider should handle the prior authorization for you. However, you should always verify the status
of an authorization prior to receiving the service. You can do this by contacting Member Services at
(715) 552-4300 or (888) 203-7770.
Please note: If you receive a service that requires an approved prior authorization by the Cooperative
and the authorization was not obtained or the prior authorization was denied, all services received
will be denied and payment may fall to member responsibility. This includes out-of-network and
follow-up care resulting from an unauthorized service. Follow-up care includes but is not limited to,
ancillary, facility and/or professional charges related to the unauthorized services.
Prior authorization is required for the following services:
Admissions
• Admissions to a hospital for non-emergent
issues
• Admissions to rehabilitation facilities
• Admissions to skilled nursing facilities
• Admissions for sub-acute care
• Admissions for behavioral health, including
admissions to residential treatment facilities
• Admissions for emergencies: authorization
must be received within 24 hours following
admission
• Admissions to “swing bed”
Outpatient Care
• Home care, except for one maternity follow-up
visit within 48 hours after being discharged
from the hospital for a vaginal delivery or 96
hours after being discharged from the hospital
for a C-section
• Hospice services
Outpatient Therapies
Medically necessary short-term outpatient therapy
(when a covered benefit) must be prescribed and
monitored by a primary or specialty physician prior
to any services being rendered.
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Ambulance Transportation
An authorization is required for transportation
by ambulance that is not due to an emergency.
This includes both air and ground services.
Outpatient Laboratory
• Any genetic testing, such as DNA testing,
except:
• When billed in conjunction with
amniocentesis
• Or prenatal triple test or alpha-fetoprotein
(AFP), human chorionic gonadotropin
(hCG), and estriol
• When provided in conjunction with Bone
Marrow Biopsy
Prior authorization from the Health Plan is not
required for the first six visits, including the initial
evaluation, for Physical Therapy, Occupational
Therapy, Pulmonary Therapy and Cardiac Therapy.
If additional visits beyond the first six are needed,
prior authorization is required before the seventh
visit.
Prior authorization is required for speech therapy,
excluding the initial visit. Many commercial benefit
plans do not cover Speech Therapy. If speech
therapy is a covered benefit prior authorization is
required for any subsequent visits after the initial
evaluation.
group-health.com | 2503 N. Hillcrest Pkwy. Altoona WI 54720 | 715.552.4300 or 888.203.7770

Dietary Counseling Services
Dietary counseling services are a covered benefit for
commercial Cooperative members with a body mass
index (BMI) of 30 or greater. Prior authorization
from the Cooperative is not required for the first
eight visits. However, prior authorization is required
prior to the ninth visit. After 12 dietary counseling
sessions, continuing coverage is contingent on the
member’s weight loss progress.
An average weight loss of one pound per week is
required for the member to continue to receive
coverage for dietary counseling services. If the
member does not meet this criterion, he/she must
wait six months before dietary counseling service
coverage is reinstated.
Outpatient Radiology
(not performed at the time of an emergency
department evaluation or hospital admission)
• MRI
• PET Scans / SPECT Scans
• CT Scans / CTA Scans
Non-Emergent Surgeries
and Procedures
• Abortion
• Cancer clinical trials
• Circumcision not performed within
one week of birth
• Corneal Transplant/Keratoplasty
• Dental anesthesia procedures or oral surgery
not performed in an office setting
• Essure sterilization not performed in a
doctor’s office.
• Gastric surgery for obesity (including consults,
testing, and assessments prior to surgery)
• Hyperbaric Oxygen Chamber Treatment
• Intradiscal electrothermal annuloplasty (IDET)
• Non-cardiac radiofrequency ablation for
treatment of chronic pain
• Organ transplant — including bone marrow
transplant/stem cell transplant
• Pain management services in an outpatient clinic
and outpatient hospital setting
• Plastic or reconstructive surgery
• Podiatric surgery not performed in the doctor’s
office or Skilled Nursing Facility
• Sclerotherapy/Endovenous Ablation
• Temporomandibular joint (TMJ) treatment
• Uvulopalatopharyngoplasty (UVPP, UPPP)
• Any service billed with an unlisted CPT or
Category III procedure code, or previously
unlisted CPT or category III procedure code
that now has a permanent code
Prosthetics and Durable
Medical Equipment (DME)
• Continuous Passive Motion Devices (CPM)
• All other DME rental beyond 30 days or with
accumulated $300 rental charges, per item
• New or used DME purchases over $300
in billed charges, per item
• External and implantable infusion pumps and
supplies, including insulin infusion pumps
Behavioral Health and Chemical
Dependency Services
Authorization is not required for the initial six
outpatient visits when services are received from
a Cooperative contracted provider. Ongoing care,
inpatient admission, outpatient psychological
testing, day treatment, in-home therapy and
transitional care require prior authorization.
Specialized Pharmacy Services
• All outpatient injections or infusions of
medications with billed charges of $500 and
above, excluding cancer chemotherapy, and
drugs administered
in conjunction with diagnostic or radiographic
testing if the testing itself does not require
prior authorization
• Any drugs or therapies used in the diagnosis or
the treatment of infertility
• Off-label drug use
Out-of-Network Providers
If your health care provider believes you need to
obtain professional services from a provider that
is outside the Cooperative network of contracted
providers, you must obtain a Referral Event
Authorization. Contact a Member Service Advocate
at (715) 552-4300 or (888) 203-7770 if you
need additional information on this process.
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© 2013 Group Health Cooperative of Eau Claire
group-health.com | 2503 N. Hillcrest Pkwy. Altoona WI 54720 | 715.552.4300 or 888.203.7770