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Services that require prior authorization A guide for providers Services that Require Prior Authorization The following services require preauthorization for KPS Health Plan’s members. Services that require preauthorization will be denied if preauthorization is not obtained. The following list does include services that will be reviewed post service for medical necessity upon receipt of the claim. For services to be paid, the Member must be eligible on the date of service and the service must be a covered benefit. KPS offers a variety of forms to use to obtain authorization prior to rendering services. You will find a Prior Authorization Request form online at kpshealthplans.com. Please fax requests to Attn: KPS Medical Management at fax number: 360-405-9180. Providers also have the option to submit prior authorization requests online through MyKPS. These requests are routed directed to KPS via secured email. Here are some tips for getting to the fastest response to your request: • Print out forms and reply in legible handwriting prior to faxing. Unreadable forms result in mistakes and delays. • Fill form out completely. Unanswered questions result in delays. • Access forms online when you need one, rather than pre-printing and storing them. We revise forms periodically, and outdated forms may delay your request. Procedures/Services that Require Prior Authorization The following procedures/services require prior authorization from KPS. To verify Member benefits and eligibility please call Customer Service at 360-377-5576 or toll-free at 800-552-7114. This information may not be an all-inclusive list and is subject to change at any time. Some member’s health plans may have specific requirements for prior authorization that may not be listed below. Please contact Customer Service. Inpatient Hospital Admissions All services Skilled Nursing Facility Admissions Inpatient Care only Mental Health Care and Substance Use Disorder Treatment Inpatient Care only Home Health, Home IV Infusion and Hospice Care All Services Outpatient or Inpatient Procedures Anesthesia for dental procedures Bariatric Surgeries: All inpatient/outpatient obesity related surgeries Biofeedback for urinary stress incontinence (non-covered for any other diagnosis) Blepharoplasty (upper/lower lids and brow lift) Bone anchored hearing aid system (BAHA) Breast MRI Breast surgeries: All inpatient/outpatient surgeries including Breast reduction/Mammoplasty Circumcisions (except Newborns 0-28 days) Cochlear implants 1 of 3 Services that require prior authorization A guide for providers Outpatient or Inpatient Procedures, cont. Collagen injections for urinary stress incontinence Deep brain stimulation Elective convulsive shock therapy “ECT” Gamma knife surgery (stereotactic radiosurgery) Gene Expression Profiling testing, Pharmacogenomic/Pharmacological testing and Risk Prognosticator Testing Genetic testing High end radiology – PET scans, MRAs (check plan benefits for non-emergent MRIs) Hyperbaric oxygen Hyperhydrosis Hysterectomy (inpatient requests only) Implantable pumps Inpatient rehabilitation Partial hospitalization, including mental health and chemical dependency Potentially cosmetic procedures Proton beam therapy Pulse dye laser Photochemotherapy: PUVA, Broadband UVB & Narrow band UVB Light Therapy Radiofrequency ablation (any diagnosis) Removal of scars Residential treatment for mental health and chemical dependency Rhinoplasty Septoplasty Sleep surgeries (any surgeries for snoring, obesity, OSA (obstructive sleep apnea) • Adenoidectomy • Glossectomy (tongue reduction) • LAUP (Laser Assisted Uvulopalatoplasty) • Septoplasty • Tonsillectomy • Turbinate reduction • UARS (upper airway resistance syndrome): • Uvulectomy • UPP (Uvulopalatoplasty) and UPPP (Uvulopalatopharyngoplasty) Spinal Surgeries: All inpatient and outpatient surgeries Turbinate reduction Transgender services Transplants (except corneal), artificial hearts and ventricular assist devices Varicose vein treatment (any) 2 of 3 Services that require prior authorization A guide for providers Office/Outpatient Administered Drugs These are non self-administered drugs covered under the medical benefit which are provided by an outpatient facility, specialty pharmacy, at home, or by a physician in a physician’s office. See the 2015 Specialty Drug List of non self-administered drugs that require prior authorization. Pharmacy Specialty Drugs These drugs are provided by MedImpact or Diplomat. MedImpact and Diplomat will handle these prior authorization reviews. See the Pharmacy Specialty Drug List. Durable Medical Equipment Bone growth stimulators (all types) Continuous glucose monitor device CPM machines Enteral therapy Home Prothrombin Time (INR) Monitoring Device Insulin pumps Light box therapy for Seasonal affective disorder (SAD) Microprocessor- controlled upper limb and lower limb prosthesis Neuromuscular stimulators (inpatient, outpatient, trial, permanent insertion, revision, or removal) Oxygen Seat/Chair lift mechanism Synchromed pump Therapeutic devices for the feet Wound vacuums Wheelchairs (including scooters and power operated vehicles) with purchase price greater than $5,000 Any other DME with a purchase price greater than $2,500 Please contact Customer Service regarding the need for prior authorization of any other services that appear to be primarily for cosmetic reasons or considered an experimental treatment, including Category III or other new technology or procedures which do not yet have CPT codes assigned. 3 of 3 14-KPS-1407