Prior Authorization Required
We are dedicated to supporting your efforts to make sure CareSource members receive the most appropriate care in the most appropriate setting for their needs. Prior authorization is based on a combination of medical necessity, medical appropriateness and benefit limits.
Please refer to the benefits grid in the Covered Services and Exclusions section of the Provider Manual for more information on services that require a prior authorization. They include the following services:
- All Inpatient Care.
- All Abortions.
- All Home Care Services.
- Nursing Facility Services.
- Hospice Care.
- Organ Transplants.
- Durable medical equipment (DME) over the $750 billed charges.
- The $750.00 rule does not apply to the below DME/other items - these require prior authorization: The $750.00 rule does not apply to the below DME/other items - these require prior authorization:
- All powered or customized wheelchairs.
- Manual wheelchair rentals over 3 months.
- Hearing Aids.
- Contact Lenses.
- Polycarbonate lenses for members over the age of 18.
- Cosmetic procedures and plastic surgery.
- Non-Formulary Drug Requests.
- Ambulance and ambulette transportation - except for emergent or facility-to-facility transfers.
- Services beyond benefit limits: This includes chiropractic care, dental care, optometry services, some mental health services, physical/occupational therapy, and speech therapy/hearing testing beyond benefit limits.
- Food supplements/nutritional supplements
The following dental services will require prior authorization as of 8/1/2008:
- Root Canals - if 3 or more root canal procedures are scheduled within 6 months
- Orthodontia Treatment
- All dentures
- All partial dentures
- Porcelain crown fused to noble metal (authorized for permanent anterior teeth only)
- Cast post and core in addition to crown (authorized for permanent anterior teeth without sufficient tooth structure to support a crown only)
- Frenulectomy/frenulotomy
- Apexification/recalcification
- Excision hyperplastic tissue
- Gingivectomy/plasty
- Impacted tooth removal - completely bony with complications
- Impacted tooth removal - completely bony
- Surgical removal of a residual tooth root
- Surgical removal of unerupted teeth
- Removal of exostosis
- Unspecified TMJ therapy
- Unspecified TMJ films
- Removable appliances
- Surgical removal of supernumerary tooth
- Fixed appliances therapy
- All unspecified/miscellaneous dental codes
CareSource will not require prior authorization for D7140. Prior Authorization for extractions for more than 4 teeth within 6 months had been planned along with other PA changes required beginning 8/1/2008 and detailed in a letter sent to all dentists earlier in July. Instead of requiring PA, Caresource will conduct claims audits to identify unusual practice patterns that might suggest excessive extractions prior to denture services.
Ø In addition, any health care provider who is not a participating provider with CareSource must obtain prior authorization for all non-emergency services provided to a CareSource member.
Ø CareSource does not require prior authorization for unlisted procedure CPT codes; however, we require a clinical record be submitted with your claim to review the validity of the unlisted procedure CPT code.
- Claims submitted without clinical records for unlisted procedure CPT codes will be denied. Denials will be reconsidered through the appeal process with pertinent clinical records.
Authorizations are not a guarantee of payment. Authorizations are based on medical necessity and are contingent upon eligibility and benefits (and other factors). Benefits may be subject to limitations and/or qualifications and will be determined when the claim is received for processing.