Prior authorization requirements

To request or check the status of a prior authorization request or decision for a particular plan member, access our Interactive Care Reviewer (ICR) tool via Availity. Once logged in, select Patient Registration | Authorizations & Referrals, and then choose Authorizations or Auth/Referral Inquiry as appropriate.

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Behavioral health

Services billed with the following revenue codes always require prior authorization:

0240 to 0249 all-inclusive ancillary psychiatric
0901, 0905 to 0907, 0913, 0917 behavioral health treatment services
0944 to 0945 other therapeutic services
0961 psychiatric professional fees

Pharmacy

Services billed with the following revenue codes always require prior authorization:

0632 pharmacy multiple sources

Pharmacy resources:

Medicare

Prior authorization is not required for physician evaluation and management services for members enrolled in the Medicare Advantage Balance (HMO) plan.

Long-Term Services and Supports (LTSS)

All services billed with the following revenue codes require prior authorization:

0023 Home health prospective payment system
0570-0572, 0579 Home health aide
0944-0945 0ther therapeutic services
3101-3109 Adult day and foster care

All long-term services and supports require prior authorization. Please use the following contact information to submit your requests.

Personal care assistants:

Phone:
1-732-452-6050 (select option 1)

Fax a request:
1-888-240-4716

Adult medical day care:

Fax a request:
1-888-240-4717

Elective services

Elective services provided by or arranged at nonparticipating facilities always require prior authorization.

Related information

Forms 

Prior authorization lookup tool 

Pharmacy information 

Provider tools & resources

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