Provider resources forpre-authorization and more

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pre-authorization request form.

Upload the evry health
pre-authorization request form.

For searchable Formulary and
Rx pre-authorization list.

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labs, asc, and home health partners.

Find additional helpful resources
go to the department of insurance.

Services Requiring Authorization

Authorization Service Category Comments

Admissions

ALL planned or scheduled inpatient admissions, includes medical, behavioral health, surgical admissions, hospice, including transfers from one facility to another

Acute Rehabilitation

ALL Inpatient Rehabilitation, Long Term Acute Care Hospital, Skilled Nursing Facilities

Ambulance or Air/Water Transport

Ambulance or Air/Water Ambulance (Non-Emergent) transport or transfer generally not covered

Any Experimental/ Investigational Services

Experimental/ Investigational medical and surgical procedures, equipment, and medications

Behavioral Health Services

Behavioral Health Services

  • Applied Behavioral Analysis (ABA)
  • Electroconvulsive Therapy (ECT) Applied
  • Neuropsychological and Psychological Testing
  • Intensive outpatient program (IOP)
  • Partial Hospitalization (PHP)
  • Residential treatment center (RTC)

Clinical trials

All clinical trials including cancer and clinical innovation

Dental

All dental related services. Generally not covered.

Dialysis

All services

Durable Medical Equipment & Prosthetics

  • All DME Rental
  • Some items require authorization.

Hematology and Oncology

Cancer treatment including chemotherapy, radiation, and surgery; Submit treatment plan as soon as known to facilitate rapid approval of necessary services

Imaging Advanced & Diagnostic Procedures

Arteriogram, Angiograms, CT/CTA scans, MRIs/MRAs, PET scans (exception breast MRI doesn’t require preauthorization)

Gene Therapy and Molecular Diagnostic Testing

  • Cancer treatment including chemotherapy, radiation, and surgery; Submit treatment plan as soon as known to facilitate rapid approval of necessary services
  • All gene therapy
  • In network lab: Quest Diagnostics and Bioreference (see website for up to date in network provider information)

Home Services* (plan specific benefit)

In network home health: see provider directory for up to date information

  • Home care
  • Home infusion services
  • Home hospice services after first 6 months
  • Total parental nutrition
  • Medical foods or enteral nutrition (oral foods generally not covered)

The following surgeries when performed in an Inpatient, Outpatient, or office location.

Includes:

  • Back injections (ESI, RFA, MBB, Facet, ect.)
  • Bariatric Surgery
  • Blepharoplasty - Brow Lift
  • Breast Procedures
  • All Cosmetic surgery: not covered when performed to improve appearance
  • All infusions
  • Hyperbaric oxygen therapy
  • Photodynamic therapy
  • Spine Procedures
  • Neurostimulators
  • Ophthalmologic procedures
  • Some Joint Surgeries (Knee, Hip, Shoulder)
  • Some Ear Nose and Throat, Oral-Maxo facial, Integumentary, Gastrointestinal, Female and Male Genital, Reproductive, Ophthalmologic, Orthopedic, Neurological, Fertility
  • CAR-T Cell therapy procedures

Miscellaneous, Unlisted Codes and T Codes

  • Miscellaneous, unlisted codes and T codes are not covered, unless otherwise stated in the provider’s contract.

Physician Administered Drugs: Some Specialty Rx/Infusions

  • Most drugs require prior authorization eg. biologicals, supportive care drugs, immunoglobulins, viscosupplementation, etc. Please see the list below for common examples, call Evry Health to confirm if physician administered drug is not listed below.

Plan Specific Provisions: Check member benefit/eligibility for eligibility.

  • Child Developmental Delays for rehabilitative and habilitative services
  • Home Health which includes a limit to 60 visits per calendar year combined modalities
  • Treatment of Mental or Emotional Illness or Disorder when confined to a hospital or Psychiatric Day Treatment Facility
  • In-Vitro Fertilization/Fertility
  • Speech and Hearing Assistance
  • Bariatric Surgery
  • Transgender Services

Transplants and Transplant related services

  • All Transplants
    • Includes Transplant Evaluations, Pre- & Post- Operative Services/Care