List of procedure - Authorization required

All of the following procedures and services require Prior Plan Notification and must be provided in a SHP participating facility*:

o Inpatient and Observation Admissions, as noted above
o Admission to any rehabilitation and skilled nursing facility
o All surgical procedures, inpatient or outpatient
o The following have special reporting requirements (refer to Forms Section):
*  Abortions
*  Hysterectomies
*  Sterilization procedures
o Cosmetic or Reconstructive Surgery, including but not limited to:
*  Breast reconstruction or reduction
*  Blepharoplasty
*  Venous procedures
*  Sclerotherapy
o Services and items:
*  Allergy (immunotherapy), exept for those services identified on the QAF
*  Ambulance transportation (non emergent)
*  Amniocentesis
*  Cardiac and pulmonary rehabilitation programs
*  Circumcisions after 12 weeks of age
*  Court-ordered services
*  Chemotherapy
*  Dialysis
*  DME, including apnea monitors and bili-blankets
*  Upper endoscopies at colonoscopies at hospitals
*  Genetic testing
*  Gamma Knife, Cyberknife
*  Hearing aids
*  Home Health Services
*  Hospice care
*  Hyperbaric Oxygen Therapy (HBO)
*  Investigational and experimental procedures and treatments
*  IV Infusions
*  Laboratory services in POS 22 and 24
*  Lithotripsy
*  Mental Health (See Mental Health Section)
*  Nutritional counseling
*  MRI’s, MRA’s
*  Oral Surgery
*  Oxygen therapy and equipment
*  Out-of-Network Services
*  Pain Management and or Pain Injections
*  PET Scans
*  Prenatal care
*  Orthotics and Prosthetics, including Cranial Orthotics
*  Physical, Occupational and Speech Therapy
*  Radiation therapy
*  SPECT scans
*  Transplants and pre and post transplant evaluations
*  Wound Care and wound vacuums
*  Drugs that require pre-authorization
*  Any services or procedures not listed on the Quick Authorization Form (QAF)

*Unless the service is only available in a non-participating facility.