Prior Authorization
Prior Authorization is required for the services detailed below. If you are being treated/seen by an out-of-network provider, it is your responsibility to obtain or verify that a prior authorization has been obtained. Failure to obtain a prior authorization may result in a denial of claims.
This list identifies categories of services requiring prior authorization. If you have questions regarding specific services please contact the Lovelace Senior Plan Customer Care Center at 505.727.5400 or toll free at 800.808.7363.
Prior authorization for Inpatient Services
The following inpatient services require prior authorization
- Medical/surgical/maternity Inpatient admission
- Behavioral Health inpatient admission
- Inpatient rehabilitation services
- Long-term acute hospital care
- Skilled Nursing facility care
- Behavioral Health partial Hospitalization
- Residential behavioral health
- Inpatient detoxification
- Inpatient substance abuse rehabilitation
- Inpatient hospice care
Prior authorization for other medical/surgical services
- Selected medical/surgical procedures, including, but not limited to:
- Cosmetic or reconstructive surgery
- Bariatric or weight loss surgical procedures
- Some cardiology procedures
- Sleep studies
- Pain management
- Dental Services
- Magnetic Resonance Imaging (MRI), computed Tomography (CT) and Positron Emission Tomography (PET) scans
- Nuclear medicine
- Genetic Testing andcounseling
- Treatment of Genetic Inborn Errors of Metabolism Disorders (IEM)
- Cancer clinical trials
- Durable Medical Equipment (DME) and supplies
- Prosthetic appliances and orthotics
- Medical supplies
- Certain injectables received in the provider’s office
- Investigational or experimental services
- Treatment of morbid obesity
- Physical, occupational, and speech therapy
- Transplants
- TMJ
- Treatment for infertility
- Non-emergent ambulance transport
Receiving Prior Authorization is not a guarantee of payment. Coverage includes verification of Benefit Plan coverage, Limitations and Exclusions and Eligibility Requirements. If Prior Authorization is not obtained when required, services may not be covered under your plan. To ensure a necessary Prior Authorization has been obtained, contact the Lovelace Senior Plan Customer Care Center.
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