Services requiring prior authorization must be reviewed in advance of the service even if PHP is a secondary payor.
PHP Notification/Prior Authorization/Prior Approval Table is not an all-inclusive list of all possible services and medications that may require prior approval/authorization. It depends on the member's specific plan as to which of these services or medications do require prior approval/authorization.
Not otherwise classified, unspecified, unlisted, miscellaneous CPT or HCPCS services- services will be reviewed prior to claim payment and may be denied as: criteria not met, cosmetic, investigational, experimental, unproven, or not medically necessary services.
PHP Notification/Prior Approval Table does not define benefit coverage. Benefit coverage is determined by the Member's COC or SPD. This means that there may be services and medications listed in this document that are not covered under a particular member's COC or SPD.
Non-emergent/urgent requests for benefit review are to be submitted at least 9 days in advance of the service or as soon as the service is determined to be appropriate by the practitioner. Urgent requests are requests for care or treatment for which a routine application of time periods for making the determination could seriously jeopardize the life or health of the member or the member's ability to regain maximum function or in the opinion of a practitioner would subject the member to severe pain that cannot be adequately managed without the care or treatment that is included in the request.
To obtain a Notification Prior Approval form please click here
Click here to view the provider notification prior approval table.