Service Authorizations

Overview

Many health care services require service authorization. It is the responsibility of your medical provider to contact the appropriate agency to authorize these services before providing them.

Requirements

Authorization is required and issued for Medicaid recipients based on service category.

Recipients

Many health care services require prior authorization. It is your medical provider's responsibility to contact them for authorization before providing the service. If you have questions about your coverage, call the Recipient Helpline: 800-780-9972.

Health care providers

Many health care services require prior authorization for Medicaid recipients. The agencies listed below are approved to provide authorization for specific services. Please view the services under each agency to determine the appropriate contact.

Program information

Division of Health Care Services (HCS)

HCS authorizations include the following:

• All non-emergent, medically necessary transportation and accommodation services
• Select professional services (physician, advanced nurse practitioner, medical clinic, dentist, etc.) as indicated in billing manuals/fee schedules
• Services in excess of annual or periodic service limitations stipulated in regulations as indicated in manuals/fee schedules
• Most Durable Medical Equipment, selected medical supplies, and selected hearing aids as indicated in billing manuals/fee schedules
• All respiratory therapy
• All home health care services
• All private duty nursing
• All hospice care
• Certain maternal/newborn admissions
• Selected pharmaceutical drugs as specified on Drugs Requiring Prior Authorization
• Outpatient Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Positron Emission Tomography (PET), and Single-Photon Emission Computed
• Selected inpatient and outpatient procedures and diagnoses, regardless of length of stay (see Select Diagnoses and Procedures PRE-CERTIFICATION List)

See prior-authorized drugs

Comagine Health Prior Authorization List

Division of Senior and Disabilities Services (SDS)

SDS authorizations include the following:

• Administrative wait and swing bed stays at acute care facilities and all long-term care (LTC) facility admissions and continued stays
• Home and community-based waiver services
• Personal care attendant (PCA) services

Division of Behavioral Health (DBH)

DBH, through Comagine Health, provide authorization for the following behavioral health services:

• Residential Psychiatric Treatment Center (RPTC) admissions and continued stay reviews
• All inpatient psychiatric admissions and continued stays exceeding three (3) days

Resources