Prior Authorization is a system providers must use to receive approval so that certain health care services and benefits will be covered by Lovelace State Coverage Insurance. The provider must receive approval from Lovelace before members may receive certain services. Below is a list of services requiring Prior Authorization. These services require oversight by Lovelace or are limited benefits and have time limits for when services can be provided.
Below are the covered services and supplies that require prior authorization:
- All out of network services except emergent, urgent or family planning services
- Acupuncture
- Durable medical equipment* and medical supplies*
- Home health care
- Grant funds for Native Americans
- Community health advocate services
- Inpatient care*:
- Acute hospital (except as otherwise prohibited by law, EMTALA, and Newborn and Mothers Health Protection Act)
- Inpatient mental health and substance abuse, including partial hospitalization
- Long term acute care facility
- Rehabilitation facility
- Skilled nursing facilities limited to a step-down unit for post-acute inpatient treatment for purposes of rehabilitation*
- Home births and out-of-hospital births through the Birthing Options Program
- Organ and tissue transplants
- Outpatient services:
- Dental care for injured teeth
- MRI, MRA and CT scans
- Sleep studies
- TMJ treatment
- Prescription drugs – most injectable medication and generic and brand name drugs not on the Lovelace SCI formulary
- Prosthetics and orthotics*
- Reconstructive surgery
- Therapies* physical, speech and occupational
* Subject to benefit limitations.
The responsibility for obtaining prior authorization is as follows:
- Contracted (In-Network) Providers: When you seek services from an In-Network Provider, the provider is responsible for obtaining prior authorization from Lovelace SCI before providing the covered services.
- Non-contracted (Out of Network) Providers: When you seek services from an out of network provider, you are responsible for ensuring that prior authorization is obtained from Lovelace SCI before obtaining the covered services. You or the out of network provider should contact the Customer Care Center.
If coverage under this plan ends, services received after coverage ends will not be covered, even if prior authorization was obtained from Lovelace SCI. Obtaining prior authorization does not guarantee that you will receive benefits.
Approval and Denial Decisions
Lovelace SCI approves payment for services. Lovelace SCI does this based on a member’s medical need. The service also has to be a covered benefit. Lovelace SCI does not financially reward anyone for denying payment of services. This includes Lovelace SCI employees. It also includes providers or other contractors. Lovelace SCI does not provide financial incentives to encourage less use of services.
2009-MKT-HSD 360
2009-MKT-SCI 120
