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Services Requiring Prior Authorization

When services requiring prior authorization are necessary for a member, the health care professional or provider should contact Select Health Medical Services toll free at 1-888-559-1010 (1-843-764-1988 in Charleston).

Providers may not bill members for services that require prior authorization and the authorization was not obtained, resulting in denial of the claim. Providers are responsible for obtaining prior authorization.

Authorization is not a guarantee of payment. Other limitations or requirements may apply. Prior authorization requirements also pertain to secondary claims.

Prior authorization is required but not limited to certain services, as indicated below. These requirements are inclusive of secondary coverage.

Services

  • Air ambulance.
  • All out-of-network services (with exceptions noted under: Does not require authorization).
  • All unlisted miscellaneous and manually priced codes (including, but not limited to, codes ending in “99”).
  • Behavioral health (psychological and neuropsychological testing, electroconvulsive therapy, environmental intervention, interpretation or explanation of results, unlisted psychiatric services).
  • Behavioral health individual outpatient therapy sessions (CPT codes 90832, 90834, 90837). Visits over six sessions per month for members ages 20 and under.
  • Chiropractic care (six visits per fiscal year, July 1 through June 30).
  • Cochlear implantation.
  • Contact lenses (including dispensing fees).
  • DAODAS services (bundled services and some discrete services).
  • Gastric bypass/vertical band gastroplasty.
  • Hyperbaric oxygen.
  • Hysterectomy (Hysterectomy Consent form required) — oophorectomy and ovarian cystectomy, elective abortions.
  • Implants (over $750).
  • Rehabilitative behavioral health services (RBHS) — see Behavioral Health Services under First Choice in the Select Health Provider Manual for specifics.
  • Transplants, including transplant evaluations.

Therapy (speech, occupational, and physical)

  • Speech, occupational, and physical therapy require prior authorization after initial assessment or re-assessment. This applies to private and outpatient facility based services.

Plastic surgery

Surgical services that may be considered cosmetic, including, but not limited to:

  • Blepharoplasty.
  • Mastectomy for gynecomastia.
  • Mastoplexy.
  • Maxillofacial (all codes applicable).
  • Panniculectomy.
  • Penile prosthesis.
  • Plastic surgery/cosmetic dermatology.
  • Reduction mammoplasty.
  • Septoplasty.

Durable medical equipment (DME)

  • Items with billed charges equal to or greater than $750.
  • DME leases or rentals and custom equipment.
  • Diapers/pull-ups (ages 4 – 20) who qualify for quantities over 200/ month (for one or both) or brand-specific diapers.
  • Enteral nutritional supplements and supplies.
  • Prosthetics and custom orthotics.
  • All unlisted or miscellaneous items, regardless of cost.

Inpatient

  • All inpatient hospital admissions, including medical, surgical, and rehabilitation.
  • Behavioral health.
  • Obstetrical admissions, newborn deliveries exceeding 48 hours after vaginal delivery and 96 hours after cesarean section.
  • Medical detoxification.
  • Elective transfers for inpatient and/or outpatient services between acute care facilities.
  • Long-term care initial placement (if still enrolled with the plan).

Home-based services

  • Home health care (physical, occupational, and speech therapy) and skilled nursing (after six combined visits, regardless of modality).
  • Home infusion services and injections (see pharmacy list of HCPCS codes that require prior authorization PDF).
  • Home health aide services.
  • Private duty nursing (extended nursing services), covered when medically necessary for under age 21.

Pharmacy and medications

Contact PerformRx℠:

Note: Medications not listed on the South Carolina Medicaid Professional Services Fee Schedule are not covered by First Choice.

Pain management

  • External infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation, nerve blocks, and epidural steroid injections.

Advanced outpatient imaging services

  • Nuclear cardiology.
  • Computed tomography angiography (CTA).
  • Coronary computed tomography angiography (CCTA).
  • Computed tomography (CT).
  • Magnetic resonance angiography (MRA).
  • Magnetic resonance imaging (MRI).
  • Myocardial perfusion imaging (MPI).
  • Positron emission tomography (PET).

Contact National Imaging Associates (NIA) or call 1-800-424-4895.

Services requiring notification

  • All newborn deliveries.
  • Maternity obstetrical services (after first visit) and outpatient care (includes 48-hour observation).
  • Behavioral health — crisis intervention: notification required (within two business days) post-service. Medical necessity review required after 80 units per state fiscal year (July 1 through June).
  • Continuation of covered services for a new member transitioning to the plan the first 90 calendar days of enrollment.

Does not require authorization

  • Emergency room services (in network and out of network).
  • 48-hour observations (except for maternity — notification required).
  • Low-level plain films — X-rays, electrocardiograms (EKGs).
  • Family planning services.
  • Post-stabilization services (in network and out of network).
  • Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services.
  • Women’s health care by in-network providers (OB/GYN services).
  • Routine vision services.
  • Post-operative pain management (must have a surgical procedure on the same date of service).
  • Behavioral health and substance use disorder outpatient therapy:
    • Members ages 20 and under require prior authorization for more than six sessions per month of all combined individual therapy sessions (codes 90832, 90834, and 90837).
    • Members ages 21 and older — benefit limitation of 72 sessions per fiscal year for all combined individual therapy sessions (codes 90832, 90834, and 90837).
  • Behavioral health medication management.

All services are subject to retrospective review to validate the request. This list is not all inclusive.