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Prior Authorization Requirements

Some services need Prior Authorization through Partners Health Plan Utilization management.  See below to learn more. 

What services need Prior Authorization through PHP's Utilization Management?

The services below need Prior Authorization. 

* Service requires authorization during Participant's 90-day continuity of care period.

  • Ambulatory Surgery Procedures*
    • Abdominoplasty
    • Blepharoplasty
    • Mastoplexy
    • Otoplasty
    • Keloid & Scar Revisions
    • Mammoplasty, Reduction or Augmentation
    • Surgical Treatment of Gynecomastia
    • ENT Procedures (Rhinoplasty, Septoplasty,
      Uvoluplasty, LAUP)
    • Varicose Veins Treatment
    • Ventral Hernias
    • Bariatric Surgery
  • Home Health Care Services
    • Does not includes CDPAS & PCA as IDT team will approve
    • Initial Assessment – Nursing, OT, PT, Speech, Nutritional Counseling and Pulmonary Therapies no auth required.
  • Home Infusion Services
  • Inpatient Admissions*
    • Acute Care Facilities, including Inpatient OBGYN
    • Skilled Nursing Facilities / Nursing Home
    • Behavioral Health Care Facilities
      • Elective Admissions
      • Urgent / Emergent Admissions
      • Substance Abuse and Rehabilitation
    • Inpatient Rehabilitation Facilities
  • Medical Social Services*
  • Nerve Block / Epidurals*
  • Organ Transplant Evaluation & Services*
  • Rehabilitation Services – Outpatient
    • Physical Therapy
    • Occupational Therapy
    • Speech Therapy
    • Pulmonary & Cardiac Rehabilitative Therapy
    • Nutritional Counseling
  • Radiology *
    • MRI
    • Functional MRI
    • MRA
    • PET
  • Private Duty Nursing
  • Outpatient Services *
    (below services only)
    • Chiropractic Services
      • No PA required for subluxation of spine.
      • Any other services require prior auth
    • Podiatry – 4 Annual Visits
      • 4 routine visits covered per year without UM review.
      • All other podiatry visits will require UM approval
  • Other Services*
    • Hyperbaric Oxygen Treatment
    • Investigation & Experimental Treatment

How does a provider obtain Prior Authorization for these services?

Obtain the Prior Authorization Request Form

Complete the form and fax, along with all pertinent clinical information, to Utilization Management at 855-769-2509

 Call Utilization Management if you have any questions at 855-769-2508

What services require Prior Authorization through Partners Health Plan Care Coordination Team?

  • Adult Day Health Care

  • Assertive Community Treatment

  • Continuing Day Treatment

  • Consumer Direction Personal Assistance Services (CDPAS)

  • DME / Prosthetics / Orthotics

  • Enteral / Parenteral Nutrition

  • Personalized Recovery Oriented Services

  • Personal Care Services

  • Personal Emergency Response Services

  • Office for People with Developmental Disabilities (OPWDD) Home and Community-Based (HCBS) Waiver Services