Services That Require Prior Authorization

What to know before you get care

Some Medicare-covered services need approval from Elderplan before you receive them. This is called prior authorization. This page lists the Medicare-covered services that require prior authorization under your Elderplan for Medicaid Beneficiaries (HMO-POS D-SNP) plan.

Your provider should contact us before providing any care on this list. If you are unsure whether a specific service requires authorization, call Member Services before your appointment.

Senior man looking at a computer with his physician

Inpatient & Facility Stays

Service	What you should know
Inpatient hospital care	Includes acute care, rehabilitation hospitals, and long-term care hospitals. Authorization is required for all planned admissions. Emergency admissions do not require prior authorization.
Inpatient psychiatric hospital	Authorization is required for inpatient psychiatric admissions.
Skilled nursing facility (SNF) care	Authorization is required. The plan covers up to 100 days per benefit period. A minimum of 3 days’ prior inpatient hospital stay for a related illness or injury is required.

Outpatient & Rehabilitation Services

Service	What you should know
Physical therapy, occupational therapy, and speech/language pathology	Authorization is required in all outpatient settings — including hospital outpatient departments, independent therapy offices, Comprehensive Outpatient Rehabilitation Facilities, and other outpatient settings.
Partial hospitalization services	Authorization is required for partial hospitalization behavioral health programs.
Intensive outpatient services (IOP)	Authorization is required for intensive outpatient behavioral health programs.
Cardiac rehabilitation (including intensive cardiac rehabilitation)	Authorization is required. Covered for members who meet Medicare coverage criteria with a doctor’s order.
Pulmonary rehabilitation	Authorization is required.
Supervised Exercise Therapy (SET) for peripheral artery disease (PAD)	Authorization is required. Covered for up to 36 sessions over a 12-week period for members with symptomatic PAD who meet Medicare criteria.
Home health agency care	Authorization is required. A doctor must certify that you need home health services and that you are homebound before services begin.
Outpatient therapeutic radiological services	Authorization is required for outpatient therapeutic radiology services (e.g., radiation treatment for cancer).
Outpatient diagnostic radiological services (selected)	Authorization is required ONLY for: Positron Emission Tomography (PET), Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), and CAT Scan (CT). Standard X-rays and other diagnostic imaging do not require authorization.
In-home physician visits (non-PCP)	Authorization is required for in-home physician visits billed by a doctor other than your PCP. Standard in-office visits do not require authorization.
In-home visits billed by a Nurse Practitioner or Physician Assistant	Authorization is required specifically for in-home visits billed directly by a Nurse Practitioner or Physician Assistant. In-office visits by NPs and PAs do not require authorization.

Equipment, Devices & Supplies

Service	What you should know
Durable Medical Equipment (DME) — certain items only	Authorization is required for certain high-dollar, motorized, and custom equipment. Not all DME requires authorization. Examples that typically require authorization include power wheelchairs, custom orthotics, and home oxygen equipment. Ask your provider or call Member Services to confirm before ordering.
Continuous Glucose Monitors (CGM)	Authorization may be required. CGM devices (Freestyle Libre) and related supplies are covered with a $0 copayment at participating pharmacies. Contact Member Services or ask your provider to confirm whether authorization is needed before you proceed.
Medical supplies	Authorization is required for medical supplies.
Prosthetic devices and orthotics	Authorization is required for prosthetics (such as artificial limbs) and orthotics (such as braces). Includes replacement and repairs due to breakage, wear, or changes in the member’s physical condition.
Hearing aids	Authorization from a physician or specialist is required before a hearing aid is dispensed. Do not order a hearing aid before authorization has been obtained.
Home infusion therapy — medical supplies	Authorization is required for medical supplies used in home infusion therapy.
Home infusion therapy — DME	Authorization is required for certain DME items used in home infusion, including high-dollar, motorized, and custom equipment. Not all home infusion DME requires authorization.
Home infusion therapy — Medicare Part B drugs	Authorization may be required for certain Medicare Part B drugs administered through home infusion. Confirm with your provider or call Member Services for your specific medication.

Ambulance Services

Service	What you should know
Non-emergency ambulance transport	Authorization is required. The member’s medical condition must be documented as requiring ambulance transport (i.e., the member cannot be safely transported by other means).
Emergency ambulance transport	Authorization is NOT required. Emergency ambulance is always covered without prior approval.

Podiatry

Service	What you should know
Medicare covered and routine	Authorization is required.

Dental

Service	What you should know
Comprehensive Dental	Authorization is required.

This is not a complete list of all covered services — only those requiring authorization.
Services not on this list do not require prior approval from your plan. Your provider should always confirm with us if there is any question about whether authorization is needed for a specific service or item before scheduling.

How to Get Prior Authorization

In most cases, your doctor or specialist submits the authorization request on your behalf. You do not need to handle this yourself. For more information, learn how to get approval for care.