Services Requiring Prior Authorization

When services requiring prior authorization are necessary for a member, the health care professional or provider should submit a prior authorization request via the NaviNet provider portal. For questions about prior authorizations, contact Select Health Population Health department toll free at 1-888-559-1010 (1-843-764-1988 in Charleston).

Health care professionals or providers may not bill members for services that require prior authorization if the authorization was not obtained, resulting in denial of the claim. Health care professionals or providers are responsible for obtaining prior authorization.

Telephone or written approval is not a guarantee of reimbursement. Other limitations or requirements may apply. Prior authorization requirements are inclusive of secondary claims.

Prior authorization is required but not limited to certain services, as indicated below:

Services

• Air ambulance.
• All out-of-network services (with exceptions noted under: Does not require authorization).
• All unlisted miscellaneous and manually priced codes (including, but not limited to, codes ending in “99”).
• BabyNet services.
• Behavioral health (psychological and neuropsychological testing, electroconvulsive therapy, environmental intervention, interpretation or explanation of results, unlisted psychiatric services).
• Behavioral health individual outpatient therapy sessions, after 24 visits per state fiscal year (CPT codes 90832, 90834, and 90837, combined). Limitation: six visits per month.
• BRCA 1 and 2 — full sequence and duplication gene analysis.
• Chiropractic care (six visits per fiscal year, July 1 through June 30).
• Cochlear implantation.
• Contact lenses (including dispensing fees).
• DAODAS services (bundled services and some discrete services).
• Gastric bypass/vertical band gastroplasty.
• Hyperbaric oxygen.
• Hysterectomy (Hysterectomy Consent form required) — oophorectomy and ovarian cystectomy, elective abortions.
• Implants (over $750).
• Rehabilitative behavioral health services (RBHS) — see Behavioral Health Services under First Choice in the Select Health Provider Manual for specifics.
• Transplants, including transplant evaluations.

Therapy (speech, occupational, and physical)

• No authorization is required for members age 20 and under for the first 72 visits, nor is it required for members age 21 and over for the first 27 visits per year. Prior authorization is required following the 72nd visit for members age 20 and under, and it is required following the 27^th visit for members age 21 and over.

Plastic surgery

Surgical services that may be considered cosmetic, including, but not limited to:

• Blepharoplasty.
• Mastectomy for gynecomastia.
• Mastoplexy.
• Maxillofacial (all codes applicable).
• Panniculectomy.
• Penile prosthesis.
• Plastic surgery/cosmetic dermatology.
• Reduction mammoplasty.
• Septoplasty.

Inpatient

• Acute inpatient psychiatric facility services.
• All inpatient hospital admissions, including medical, surgical, and rehabilitation.
• Behavioral health.
• Obstetrical admissions, newborn deliveries exceeding 48 hours after vaginal delivery and 96 hours after cesarean section.
• Medical detoxification.
• Elective transfers for inpatient and/or outpatient services between acute care facilities.
• Long-term care initial placement (if still enrolled with the plan).

Home-based services

• Home health care: Speech therapy, home health aides, and skilled nursing visits (after 18 combined visits, regardless of modality).
• Home infusion services and injections. Consult the Prior Authorization Lookup tool to determine authorization requirements.
• Home health aide services.
• Private duty nursing (extended nursing services) covered when medically necessary for under age 21.

Pharmacy and medications

• 17-P injection.
• Injectable medications requiring prior authorization are indicated in the Prior Authorization Lookup tool

For questions contact PerformRx℠: 1-866-610-2773.

Note: Medications not listed on the South Carolina Medicaid Professional Services Fee Schedule are not covered by First Choice.

Advanced outpatient imaging services

• Nuclear cardiology.
• Computed tomography angiography (CTA).
• Coronary computed tomography angiography (CCTA).
• Computed tomography (CT).
• Magnetic resonance angiography (MRA).
• Magnetic resonance imaging (MRI).
• Myocardial perfusion imaging (MPI).
• Positron emission tomography (PET).

Contact National Imaging Associates (NIA) or call 1-800-424-4895.

Services previously managed by eviCore healthcare as of February 13, 2024:

Starting February 13, 2024, all new and prior authorization requests that were previously managed by eviCore will be submitted directly to Select Health for the following services:

• Diagnostic sleep testing.
• Durable medical equipment.
• Genetic testing.
• Joint & spine surgery.
• Medical oncology.
• Occupational therapy.
• Pain management.
• Physical therapy.
• Radiation oncology.

If you have questions regarding this change, please call 1-888-559-1010 (1-843-764-1988 in Charleston).

Services requiring notification

• All newborn deliveries.
• Maternity obstetrical services (after first visit) and outpatient care (includes 48-hour observation).
• Behavioral health — crisis intervention: notification required (within two business days) post-service. Medical necessity review required after 80 units per state fiscal year (July 1 through June).
• Continuation of covered services for a new member transitioning to the plan the first 90 calendar days of enrollment.

Does not require authorization

• Emergency room services (in network and out of network).
• 48-hour observations (except for maternity — notification required).
• Low-level plain films — X-rays, electrocardiograms (EKGs).
• Family planning services.
• Post-stabilization services (in network and out of network).
• Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services.
• Women’s health care by in-network providers (OB/GYN services).
• Routine vision services.
• Outpatient Psychotherapy codes 90832, 90834, and 90837 (combined) first 24 visits.
• Behavioral health medication management.
• Opioid treatment program services.
• Enteral nutritional supplements.

All services are subject to retrospective review to validate the request. This list is not all inclusive.