Common use of Services that Require Prior Authorization Clause in Contracts

Services that Require Prior Authorization. a. Members should remember that services provided or received without Prior Authorization from AvMed when authorization is required, are not covered except when required to treat an Emergency Medical Condition. Furthermore, if an inpatient admission is extended beyond the number of days initially approved, without Prior Authorization for the continued stay, it may result in services not being covered. Before a service is performed, you should verify with your Health Professional that the service has received Prior Authorization. If you are unable to secure verification from your Health Professional, you may also call AvMed at ▇-▇▇▇-▇▇▇-▇▇▇▇. b. Services that require Prior Authorization from AvMed include: i. inpatient admissions (including Hospital and observation stays, Skilled Nursing Facilities, Ventilator Dependent Care, acute rehabilitation and inpatient mental health or substance abuse services); ii. surgical procedures or services performed in an outpatient Hospital or Ambulatory Surgery Center; iii. complex diagnostic and therapeutic, and sub-specialty procedures (including CT, CTA, MRI, MRA, PET, and nuclear medicine); iv. radiation oncology; v. certain medications including Injectable Medications, and select medications administered in a Physician’s office, an outpatient Hospital or infusion therapy setting; vi. all Home Health Care Services; vii. cardiac rehabilitation; viii. dialysis services; ix. transplant services; x. non-emergency transport services; xi. care rendered by Non-Participating Providers (except for Emergency Medical Services and Care). c. Services requiring Prior Authorization may change from time to time. For more information about which services require Prior Authorization, contact ▇▇▇▇▇’s Member Engagement Center at 1-800- 882-8633. You should always make sure your Physician contacts us to obtain Prior Authorization.

Services that Require Prior Authorization. a. Members should remember that services provided or received without Prior Authorization from AvMed AvMed, when authorization is required, are not covered except when required to treat an Emergency Medical Condition. Furthermore, if an inpatient admission is extended beyond the number of days initially approved, without Prior Authorization for the continued stay, it may result in services not being covered. Before a service is performed, you should verify with your Health Professional that the service has received Prior Authorization. If you are unable to secure verification from your Health Professional, you may also call AvMed at ▇-▇▇▇-▇▇▇-▇▇▇▇. b. Services that require Prior Authorization from AvMed include: i. inpatient admissions (including Hospital and observation stays, Skilled Nursing Facilities, Ventilator Dependent Care, acute rehabilitation and inpatient mental health or substance abuse services); ii. surgical procedures or services performed in an outpatient Hospital or Ambulatory Surgery Center; iii. complex diagnostic and therapeutic, and sub-specialty procedures (including CT, CTA, MRI, MRA, PET, and nuclear medicine); iv. radiation oncology; v. certain medications including Injectable Medications, and select medications administered in a Physician’s office, an outpatient Hospital or infusion therapy setting; vi. all Home Health Care Services; vii. cardiac rehabilitation; viii. dialysis services; ix. transplant services; x. non-emergency transport services; xi. care rendered by Non-Participating Providers (except for Emergency Medical Services and Care). c. Services requiring Prior Authorization may change from time to time. For more information about which services require Prior Authorization, contact ▇▇▇▇▇’s Member Engagement Center at 1-800- 882477-86338768. You should always make sure your Physician contacts us to obtain Prior Authorization.

Services that Require Prior Authorization. a. Members should remember that services provided or received without Prior Authorization from AvMed when authorization is required, are not covered except when required to treat an Emergency Medical Condition. Furthermore, if an inpatient admission is extended beyond the number of days initially approved, without Prior Authorization for the continued stay, it may result in services not being covered. Before a service is performed, you should verify with your Health Professional that the service has received Prior Authorization. If you are unable to secure verification from your Health Professional, you may also call AvMed at ▇-▇▇▇-▇▇▇-▇▇▇▇. b. Services that require Prior Authorization from AvMed include: i. inpatient admissions (including Hospital and observation stays, Skilled Nursing Facilities, Ventilator Dependent Care, acute rehabilitation and inpatient mental health or substance abuse services); ii. surgical procedures or services performed in an outpatient Hospital or Ambulatory Surgery Center; iii. complex diagnostic and therapeutic, and sub-specialty procedures (including CT, CTA, MRI, MRA, PET, and nuclear medicine); iv. radiation oncology; v. certain medications including Injectable Medications, and select medications administered in a Physician’s office, an outpatient Hospital or infusion therapy setting; vi. all Home Health Care Services; vii. cardiac rehabilitation; viii. dialysis services; ix. transplant services; x. non-emergency transport services; xi. care rendered by Non-Participating Providers (except for Emergency Medical Services and Care). c. Services requiring Prior Authorization may change from time to time. For more information about which services require Prior Authorization, contact ▇▇▇▇▇’s Member Engagement Center at 1-800- 882376-86336651. You should always make sure your Physician contacts us to obtain Prior Authorization.