UK-HMO 2016/17 PRIOR PLAN APPROVAL LIST Phone: (866) 776-4793 (Effective 7-1-16) The following Prior Plan Approval List represents services that require approval before the service is rendered. Failure to obtain prior plan approval results in 100% penalty. No retro-authorizations are allowed. Services DME Bone Growth Stimulator: Electrical or Ultrasound Communication Assisting/Speech Generating Devices External (Portable) Continuous Insulin Infusion Functional Electrical Stimulation (FES); Threshold Pump Electrical Stimulation (TES) Microprocessor Controlled Lower Limb Prosthesis Oscillatory Devices for Airway Clearance including High Frequency Chest Pneumatic Pressure Device with Calibrated Pressure Power Wheeled Mobility Devices PROSTHETICS: Electronic or externally powered and Standing Frame select other prosthetics Hospital inpatient admissions Long-term Care Mental health and substance abuse facility Organ transplants/blood and marrow transplants inpatient, partial hospital and intensive outpatient services Orthotics professionally fitted braces and splints Physical rehabilitation facility admissions — costing more than $750 Prosthetics artificial limbs Skilled Nursing Facility (SNF) admissions — Procedures, and services Abdominoplasty Accidental dental and general anesthesia benefit (except anesthesia associated with impacted teeth removal) Benign skin lesion removal (Auths not required for Blepharoplasty UK Providers) Breast reduction/augmentation (Breast Cochlear implant reconstruction procedures needs no precert with diagnosis of cancer) *Hyperbaric Therapy Medication Preauthorization List (see page 2) Molecular Diagnostic/Genetic Testing* Neuropsychological testing Non-participating Physician/Facility Requests Oral surgery (except wisdom teeth removal and associated anesthesia) Plastic or cosmetic surgery Rhinoplasty Sclerotherapy (except stab phlebectomies) Septoplasty Speech Therapy Surgery for snoring or sleep apnea (e.g. UPPP) Temporomandibular joint (TMJ) procedures Radiology Open MRIs outside UK or Samaritan Hospital (no open MRI at these facilities) Coronary CT angiography
UK-HMO 2016/17 PRIOR PLAN APPROVAL LIST Phone: (866) 776-4793 (Effective 7-1-16) The following Prior Plan Approval List represents services that require approval before the service is rendered. Failure to obtain prior plan approval results in 100% penalty. No retro-authorizations are allowed. Services DME Bone Growth Stimulator: Electrical or Ultrasound Communication Assisting/Speech Generating Devices External (Portable) Continuous Insulin Infusion Pump Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES) Microprocessor Controlled Lower Limb Prosthesis Oscillatory Devices for Airway Clearance including High Frequency Chest Pneumatic Pressure Device with Calibrated Pressure Power Wheeled Mobility Devices PROSTHETICS: Electronic or externally powered and select other prosthetics Standing Frame Hospital inpatient admissions Long-term Care Mental health and substance abuse facility inpatient, partial hospital and intensive outpatient services Organ transplants/blood and marrow transplants Orthotics — professionally fitted braces and splints costing more than $750 Physical rehabilitation facility admissions Prosthetics — artificial limbs Skilled Nursing Facility (SNF) admissions Procedures, and services Abdominoplasty Accidental dental and general anesthesia benefit (except anesthesia associated with impacted teeth removal) Benign skin lesion removal (Auths not required for UK Providers) Blepharoplasty Breast reduction/augmentation (Breast reconstruction procedures needs no precert with diagnosis of cancer) Cochlear implant *Hyperbaric Therapy Medication Preauthorization List (see page 2) Molecular Diagnostic/Genetic Testing* Neuropsychological testing Non-participating Physician/Facility Requests Oral surgery (except wisdom teeth removal and associated anesthesia) Plastic or cosmetic surgery Rhinoplasty Sclerotherapy (except stab phlebectomies) Septoplasty Speech Therapy Surgery for snoring or sleep apnea (e.g. UPPP) Temporomandibular joint (TMJ) procedures Radiology Open MRIs outside UK or Samaritan Hospital (no open MRI at these facilities) Coronary CT angiography
2016-2017%20UK-HMO%20Preauth%20List%20(effective%2007-1-16).docx