Services Requiring Authorization
The following services require Authorization by a Ped-I-Care Medical Director prior to services being rendered:
- Inpatient admissions (except emergencies, which require notification of the PCP within twenty-four (24) hours or next business day-see below) (includes behavioral health residential and day treatment programs)
- The following outpatient diagnostic services, if performed in the hospital or ambulatory surgical center setting:
- MRA/MRI
- PET Scan
- Colonoscopy/Endoscopy
- Durable Medical Equipment: DME includes all items in the Medicaid DME Handbook, plus hearing aids. This includes supplies, medical equipment, prosthetics and orthotics. Note: Authorization is not required if the item is provided as part of a covered service in a physician's office setting
- Select hearing items (L8614, L8619, V5299)
- Home health care
- Rehabilitation services (Physical Therapy, Respiratory Therapy, Occupational Therapy, Speech/Language Therapy)
- Prescribed Pediatric Extended Care (PPEC)
- Hospice
- Portable X-Ray (provided at home)
- Out-of-network service
- Payment for service units exceeding Medicaid defined limits
Requests for authorization of services should be submitted to MED3000 via fax using the Referral and Authorization Request form. The request must include relevant notes from the medical record. Faxed requests should be sent to 1-866-256-2015.
