GLO-PRV-Authorization-Clear Coverage-Expiration Date Notice
Effective immediately through the end of 2019, please enter December 31, 2019 as the end date unless a shorter time frame is warranted.
Beginning January 1, 2020, please select an end date of December 31, 2020 unless a shorter time frame is warranted.
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Search for Required Medical Services-Request Authorization Page Tab Content
GLO-PRV-Search Authorization Page-Row 1 Content
The medical services including provider administered drugs below require prior review by the plan to determine clinical medical necessity.
Authorization - Preauthorization - Basic Web Content
The services below require prior review by the Plan to determine clinical medical necessity for all places of service. Not all services are covered by all medical plans. There may be services that require preauthorization or notification that do not require clinical review. Final determination of coverage is subject to the member’s benefits and eligibility on the date of service.
- All eviCore services can also be validated for prior authorization requirements via eviCore.com
Who Can Request: For HMO/POS plans, the member’s PCP or specialist with a valid referral. Other members, the member's PCP or treating provider.
Medical Health Procedure Codes Requiring Prior Authorization:
- Prior Authorization Guidelines Code List - January 17, 2020Open a PDF
- Prior Authorization Guidelines Code List - January 1, 2020Open a PDF
- Durable Medical Equipment - January 17, 2020Open a PDF
- Durable Medical Equipment - January 1, 2020Open a PDF
- Sleep Management Program Update
- Medical Specialty Drug (For Commercial, Essential Plan, Exchange and Medicare)Open a PDF
- Medical Specialty Drug (For Medicaid and Child Health Plus)Open a PDF
- eviCore Codes Requiring Preauthorization - Master GridOpen a PDF
Behavioral Health Procedure Codes Requiring Preauthorization:
- Commercial Medicare & Child Health Plus Products - July 1, 2019Open a PDF
- Managed Medicaid & Health and Recovery Plan Products - July 1, 2019Open a PDF