Attachment A: Services Requiring Treatment Authorization Requests

Services that require Treatment Authorizations prior to the rendering of care include:

  • Ambulance Transport (and other non-emergency transport)
  • Ambulatory Surgery Services
  • Angiographies
  • Audiological Services
  • Bone Density Studies
  • Cardiac Catheterization
  • Cardiac Rehabilitation
  • Chemical Dependency Services
  • Child Development Services
  • CT Scans
  • Durable Medical Equipment (DME), including oxygen, prosthetics and corrective appliances
  • Gamma Immune Therapy
  • Holter Monitoring
  • Home Health / Home Infusions Services
  • Hospice Care
  • Hospital Admissions (elective)
  • Laboratory, Radiology Procedures costing over $300
  • Lithotripsy
  • Magnetic Resonance Imaging (MRI scans)
  • Maternity hospital admissions outside of standard care
  • Mental Health Services
  • Nuclear Medicine Studies
  • Nutritional Counseling (all types)
  • Obstetric Procedures and/or Tests Outside of Standards
  • Occupational Therapy / Physical Therapy (outpatient)
  • Office Procedures over $300
  • Ophthalmic Procedures (excluding office-based procedures)
  • Orthotics and Prosthetics
  • Out-of-Network Services
  • Pentamidine Treatment
  • Podiatric Surgery (including office-based surgery)
  • Psychological Testing
  • Pulmonary Function Tests (other than baseline spirometry)
  • Radiation Therapy
  • RAST Testing
  • Rehabilitation Services
  • Renal Dialysis
  • Respiratory Therapy (outpatient)
  • Skilled Nursing and Intermediate Care
  • Sleep Monitoring / Sleep Studies
  • Speech Therapy
  • Treadmill Stress Test
  • Ultraviolet Light Treatment
  • Ultrasounds (hospital based –except for OB)


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