Authorization Requirement List

Medicare Advantage

Prior Approval List Effective 3/5/2012 Click here for a pdf version

  • All services performed by non‐contracted providers, physicians or vendors
  • Scheduled inpatient admissions (medical, surgical and behavioral health)
  • Scheduled observation stays (medical and surgical)
  • Skilled nursing facility services (PT, ST, OT provided to custodial patients does not require prior auth)
  • Part B Drugs (Call Pharmacy Department for Prior Auth Form 317.963.6830 or 866.412.8644 then fax completed form to 317.962.4070

Coverage is based on 2012 CMS approved services/items, eligibility on date(s) of service, and CMS defined medical necessity & quantity/frequency limits.

MODIFY DATE: 10/08/2012 11:00:18 AM PMMODIFIED BY: