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Prior Authorization
Services that Require Prior Authorization
Certain medical services require authorization from Capstone Health Plan prior to services being rendered. Please refer to the list below.
- Durable Medical Equipment (DME) and medical supplies
- Elective hospitalizations
- Specialty consultations
- Home health/Private duty nursing
- Hospice
- Nursing facility
- Infusion therapy
- Respiratory therapy
- Family planning
- Non-formulary medications
- Orthotics and prosthetics
- Rehabilitation therapies (PT/OT/ST)
- Non-emergency transportation
- Transplants
- Chemotherapy and/or radiation therapy
- Genetic testing
- Vision services
- Dental services
- Audiology
- Behavioral health services
- Dialysis
- Surgery and anesthesia
- Nutritional Supplements
Services that Do Not Require Prior Authorization
- Services provided by PCP
- Outpatient diagnostic studies
- Emergency department visits (facility must notify Capstone)
- Emergency hospitalizations (facility must notify Capstone)
- Prescription drugs listed on the Capstone formulary
- EPSDT services
- Emergency transportation (facility must notify Capstone)
How to Complete an Authorization Request
Providers are requested to submit a Capstone Authorization Request Form for all authorization requests. Providers are also encouraged to submit any pertinent medical documentation in support of the request. Failure to submit sufficient justification information may cause the authorization request to be denied. Pertinent documentation includes the following:
- Description of requested service
- Reason for recommendation
- Name of specialist or facility to which the patient is being referred
- Specialty of person/place to which the patient is being referred
- Address, phone number and fax number for referred specialist or facility
Deadlines for Requesting Authorization
It is Capstone Health Plans policy that all requests for authorization must be made prior to the service being rendered.
However, emergency services, such as ER admissions, must be reported to Capstone Health Plan within 24 hours of admission. Emergency transportation providers must notify Capstone within ten (10) business days from the date of service.
Failure to notify Capstone within the specified time frames may result in payment for services rendered to be denied.
