Authorization Guidelines

Summary of services that require prior authorization
Click here to download a copy of the Authorization Guidelines.  Or, view them below.

Please note that the Riverside Health Authorization Guidelines are still in effect.

2017 Guidelines Coming Soon


Obtaining prior authorization is the responsibility of the PCP or treating provider.  Members who need prior authorization should work with their provider to submit the required clinical data.

Submit the request in one of the following ways:

  • via fax to 410-779-9336
  • via telephone at 800-730-8543 / 410-779-9359.

Click here to download a copy of our preauthorization request forms. 

Important Information

  • The lists below are not all inclusive
  • All inpatient services require authorizations
  • All outpatient services in the below categories and/or outpatient services and procedures by a non-par facility or non-par provider require an authorization.
  • Authorization is not a guarantee of payment
  • All authorizations are subject to eligibility requirements and benefit plan limitations
  • Verification of eligibility and/or benefit information is not a guarantee of payment.
  • Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility, any claims received during the interim period and the terms of coverage applicable on the date services were rendered.

Out of Network

Before seeking Out of Network care members should speak with their Primary Care Physician.

The following services rendered Out of Network do not require authorization:

  • Urgent or Emergent care
  • Self-Referral Services i.e. School-Based Health Centers, family planning services, renal dialysis

Click here to view a full listing of Self-Referral Services in the member handbook.

Authorization NOT Required

Listed below are examples of services provided in an Outpatient (POS 22), Ambulatory Surgery Center (POS 24), or Office (POS 11) that do not require authorization prior to receiving services.

 

  • Acupuncture (Non Covered for Medicare)
  • Blood & Blood Products
  • Bone Mass Measurement
  • Bronchoscopies
  • Chemotherapy
  • Cancer Screening
  • Case Management
  • Cholecystectomy (laparoscopic)
  • Colonoscopy
  • Cystoscopies (Cystectomy, w/Urethroscopy, w/Lithotripsy)
  • Dental (Transfer to DentaQuest for details)
  • Diabetes (Self-Management Training, Nutritional Counseling, Screening and Supplies)
  • Dilation & Curettage (D&C)
  • Disease Management
  • Dialysis
  • Diagnostic Imaging/Therapeutic X-rays – Mammogram – Bone density – Dexa scan o Duplex scan
  • Electroencephalogram (EEG)
  • Emergency/Urgent Care (within US)
  • Endoscopies (EGD, ERCP)
  • Fractures and Dislocations
  • Hysteroscopies, Hysterectomies
  • Immunizations/Vaccinations
  • Laboratory/Pathology
  • Prenatal & Postnatal
  • Nutrition Therapy
  • Self-Referral Services for Medicaid – Family Planning Visits – School-Based Health Center Visits – Renal Dialysis
  • Physician/Practitioner Services – Primary and Specialty Consultations/Evaluations
  • Podiatry*
  • Preventive Care
  • Radiation Therapy
  • Splints, Casts
  • Vision (Transfer to Superior Vision for details)

* See Authorization Required section of Member Handbook listing benefits for exceptions.

Authorization Required

Chiropractic & Osteopathic Manipulation

All Services and Procedures involving the Manipulation of the Spine or Joints.

DME /Prosthetic

  • All Rental Services require an authorization.
  • All Purchased Equipment and/or Supplies over $500 (Certificate of Medical Necessity as applicable).
 

Home Visits

  • Home Health Visits (Skilled Nursing, Physical Therapy, Occupational Therapy, Speech Therapy, Social Work, Home Health Aide)
  • Services and Procedures performed in the home by physicians or qualified non-physician practitioners (i.e. Nurse Practitioner or Physician Assistant)
  • In some situations, like when the member is homebound and a physician provides home visits no authorization is required – refer the provider to Health Services
  • Private Duty Nursing for members under 21 years of age
  • Hospice Care
  • Home Infusion

Medical/Surgical Procedures

  • Cell Harvesting (stem cell, t-cell)
  • Biofeedback
  • Bone Marrow Biopsy, Harvesting, Transplantation
  • Bone Stimulation
  • Nerve Block, Facet Joint Injections, Chemodenervation
  • Neurostimulation
  • Skin/Subcutaneous Tissue Excisions, Acne Surgery, Dermabrasions, Chemical Peels, Plastic Surgery, Cosmetic Surgery, Removal of Lesions
  • Reconstructions, Reductions, Implantations
  • Vein Ablation Therapy, Ligation or Stripping

Pharmacy

  • Formulary and Non-Formulary products requiring a PA (Prior Authorization), QL (Quantity Limit), or ST (Step Therapy) review
  • See more below in Carve Outs/Delegation for CVS Caremark

Radiology Services

  • Computed tomography (CT)
  • Magnetic Resonance (e.g. Proton) Imaging (MRI)
  • Magnetic Resonance Angiography (MRA)
  • Positron Emission Tomography (PET)

Rehabilitative Therapies

  • Cardiac Rehabilitation (Medicaid only, Medicare authorization required only after 36 sessions exhausted)
  • Pulmonary Rehab (Medicaid only, Medicare authorization required after 36 sessions exhausted)
  • Physical Therapy (PT)
  • Occupational Therapy (OT)
  • Speech Therapy (ST)
  • Seating Evaluations

Sleep Study

  • All Services and Procedures related to Sleep Studies.

Other Services

  • Meals Post-Discharge from a Hospital or SNF
  • All CPT codes classified as Category II and all HCPCS codes classified as Unlisted by the AMA

Carve Outs/Delegation

Mental Health & Substance Use Disorder

Mental Health & Substance Use Disorder: State of Maryland’s Specialty Mental Health System toll-free at: 800-932- 3918 (Anti-Psychotic Peer Review Line for children 0-9 years old: 855-283-0876)

Dental

  • Dental for Children & Pregnant Women: Healthy Smiles 855-934-9812
  • Dental for Adults: DentaQuest 800-341-8478

Vision

Superior Vision 800-879-6901

Pharmacy

CVS Caremark 877-418-4133 Authorization requests for Formulary and Non-Formulary products requiring a PA (Prior Authorization), QL (Quantity Limit), or ST (Step Therapy) review Visit the Pharmacy section to use the Formulary Search Tool.

Non Emergent Medical Transportation

Local Health Department

Elective Abortions

Local Health Department

Outpatient PT, OT, ST & Audiology for recipients under the age of 21

Maryland Medical Assistance Beneficiary Hotline 800-492-5231

Speech Augmentation

Maryland Medical Assistance Beneficiary Hotline 800-492-5231

HIV/AIDS services (viral load, genotypic, phenotypic, or other resistance testing)

Maryland Medical Assistance Beneficiary Hotline 800-492-5231

Skilled Personal Care

Maryland Medical Assistance Beneficiary Hotline 800-492-5231

Medical Day Services

Maryland Medical Assistance Beneficiary Hotline 800-492-5231