Services That Require Prior Authorization

This page lists covered services that require prior authorization under your Elderplan Advantage for Nursing Home Residents (HMO-POS I-SNP) plan. Your provider should contact us before scheduling any service on this list. If you are unsure.

Inpatient & Facility Stays

Service	What you should know
Inpatient hospital care	Authorization is required for all planned admissions. Emergency admissions do not require prior authorization.
Inpatient psychiatric/mental health care	Authorization is required.
Skilled nursing facility (SNF) care	Up to 100 days per benefit period; a 3-day prior inpatient hospital stay is required. Authorization is required.

Outpatient & Rehabilitation Services

Service	What you should know
Physical therapy, occupational therapy, and speech-language therapy	Authorization is required.
Cardiac rehabilitation	Authorization is required.
Pulmonary rehabilitation	Authorization is required.
Supervised Exercise Therapy (SET) for peripheral artery disease (PAD)	Authorization is required. Covered up to 36 sessions over 12 weeks for members who meet Medicare criteria.
Outpatient mental health and psychiatric services	Authorization is required.
Diagnostic radiology — selected	Authorization is required ONLY for Positron Emission Tomography (PET), Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), and CAT Scan (CT). Authorization may be required for certain X-ray services.

Equipment, Devices & Supplies

Service	What you should know
Durable Medical Equipment (DME) — certain items only	Authorization is required for certain items. Ask your provider or call Member Services to confirm before ordering.
Medical supplies	Authorization is required.
Prosthetic devices	Authorization is required.

Drugs & Ambulance

Service	What you should know
Certain Medicare Part B drugs	Authorization may be required for certain drugs.
Non-emergency ambulance transport	Authorization is required. Emergency ambulance transport does not require authorization.

This is not a complete list of all covered services — only those requiring authorization. Your provider should confirm with us if there is any question about whether authorization is needed before scheduling.

How to Get Prior Authorization

In most cases, your doctor or specialist submits the authorization request on your behalf — generally through your Primary Care Provider or directly through our Prior Authorization Department. You do not need to handle this yourself. For more information on how the process works, including timeframes and your appeal rights, learn how to get approval for care.