Prior Authorizations

Some services require approval from Lovelace Community Health Plan (LCHP) before the service is provided. Without this approval or “prior authorization,” these services may not be covered by LCHP. It is up to your provider to get prior authorization for these services. If you go to an out of network provider, it is up to you to make sure the provider gets a prior authorization for the service they provide to you. The LCHP Customer Care Center can help you or your provider with any questions you may have regarding the LCHP prior authorization process. All services, except emergency services or family planning services, provided by an out of network provider must be authorized by LCHP before the service is provided. If you receive services from an out of network provider, and that provider did not get prior authorization from LCHP, you may be responsible for the provider’s charges.
For in-network providers, the services listed below require the provider to get an authorization from LCHP before the service is provided. This is not a complete list of all the possible services that may require authorization. There may be other services requested by your provider that require a prior authorization.

• All inpatient admissions
• Skilled nursing facility services
• Durable medical equipment and medical supplies including hearing aids
• Prosthetics and orthotics
• Organ and tissue transplants
• Outpatient services including:
  • MRI, MRA and CT scans
• Sleep studies
• Home births and out-of-hospital births through the Birthing Options Program
• TMJ treatment
• Dental services including the following:
  • Oral surgery
  • Treatment for injury to sound and natural tooth
  • Dental extractions
  • Crowns
  • Endodontics (braces)
  • Full and partial dentures
  • Peridontal treatment
• Acupuncture
• Bariatric surgery
• Home health care
• Reconstructive surgery
• Prescription drugs including
  • Most injectable medication
  • Generic and brand name drugs not on the LCHP formulary
• Some devices including cochlear implants or insulin pumps
• Therapies:
  • Physical, speech and occupational
  • Pulmonary and cardiac
  • Evaluations related to Early Childhood Evaluation Program, Preschool Infant Evaluation Program and Family Infant Toddler Program

For out-of-network providers (except for emergent, urgent or family planning services), Lovelace Community Health Plan (LCHP) approves payment for services. LCHP does this based on a member’s medical need. The service also has to be a covered benefit. LCHP does not financially reward anyone for denying payment of services. This includes LCHP employees. It also includes providers or other contractors. LCHP does not provide financial incentives to encourage less use of services.

2009-MKT-HSD 360

2009-MKT-SCI 120