Services requiring prior authorization
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Services Requiring Prior Authorization- Listed by CPT,
www.molinahealthcare.comHCPC, and REV code. Please Note: Not all codes referenced in this document are covered services for Ohio Medicaid Programs or all sites of service. Please be sure to identify the Medicaid program (e.g. Healthy Families, Healthy Start, ABD, Dual Options MyCare Ohio, or Adult Extension) prior to referencing this document.
Services Requiring Prior Authorization Effective February ...
networkhealth.comUpdated 1/1/2019- removed authorization requirements for total ankle replacement, septoplasty, UPPP, mattresses, hospice and life vests. 2/1/19- added Molecular genetic lab testing and medical oncology services under eviCore
Nonemegency Ambulance Prior Authorization Request
www.tmhp.comTexas Medicaid and Children with Special Health Care Needs (CSHCN) Services Program Non-emergency Ambulance Prior Authorization Request Submit completed form by fax to: 1-512-514-4205
Request for Prior Authorization 11.11.2016
www.bcbstx.comThis authorization is based on medical necessity only and will be contingent upon eligibility and benefits. This is not a guarantee of payment.