Services must be provided according to the Medicare Coverage Guidelines, established by the Center for Medicare & Medicaid Services (CMS), and are subject to review. According to the guidelines, all medical care, services, supplies and equipment must be medically necessary. You may review the Medicare Coverage Guidelines online at: https://www.medicare.gov/what-medicare-covers.
Investigational and experimental procedures are not usually covered benefits. Please consult the member’s Evidence of Coverage or contact the Health Plan for confirmation of coverage.
The Prior Authorization List allows you to quickly check if a specific procedure code or medication requires prior authorization. The Prior Authorization List is not inclusive of all services that require prior authorization (e.g., non-Medicare covered items, HCPC codes and Rev codes are not
For a list of services requiring prior authorization, please refer to the Prior Authorization List (PAL).
For a comprehensive list of the Prior Authorization, please log-on to the Provider Portal.