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Prior Authorization

How to Reach Prior Authorization Staff with an Authorization Request

When your child needs care, always start with a call to their Primary Care Provider (PCP). Some covered services may need prior approval. They may need review by Children’s Medical Services (CMS) Health Plan before services are given. This includes services or visits to an out-of-network provider. Hospital stays, transplants, home health services, medical equipment, some surgeries and medicines, require prior approval. A provider can tell you if a service needs a prior approval. The list of these services can be found below.

If you have questions, please call your child’s care manager or Member Services at 1-866-799-5321 (TTY 1-800-955-9770).

The list of services that need a prior authorization can include an admission to the hospital after an emergency condition has improved, power wheelchairs, home health visits, MRI X-rays, hospice care, genetic testing, pain management or some outpatient surgery. A PCP or other doctor that is treating your child can request an authorization from CMS Health Plan. When a doctor requests an authorization, he or she must send information about your child’s health condition and treatment. This may include copies of his or her medical record, results of tests, what medications he or she has tried, or what kind of support your child needs at home. Your child can go to any participating CMS Health Plan doctor for covered services.

The provider will give us information about why your child needs the service. CMS Health Plan will look to see if the service is covered and that it is necessary. CMS Health Plan will make the decision as soon as possible, based on your child’s medical condition. Standard decisions are made within seven calendar days. If the service is urgent, the decision will be made within 48 hours. We will let you and the doctor know if the service is approved or denied. If you or the doctor are not happy with the decision, you can ask for a second review. This is called an appeal. See the “Member Satisfaction” section in your Member Handbook. This provides more information about appeals.

If there are any major changes to the prior authorization process, we will let you and the doctors know right away.

Prior Authorization List

CMS Health Plan needs to approve in advance the services listed below. Prior approval is required for all services by a provider who is not in the CMS Health Plan network. The only exception is for emergency care. Emergency room or urgent care visits do not require prior authorization.

Services Requiring Prior Authorization

PCPs, specialists or facilities must request an authorization for the following services:

The list above indicates what services require a prior authorization. If there is no prior authorization received from CMS Health Plan, the claim for any service noted as needing a prior authorization will be denied. This is not a complete list of covered services. Limits and services that are not covered are listed in the Member Handbook. The Utilization Management department is available Monday through Friday from 8 a.m. to 6 p.m. at 1-866-799-5321, during normal working days. Nurse Advice Line staff are available 24/7 for after-hour calls.