Simply health care - services required authorization

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)

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