Services That Require Prior Authorization
This page lists Medicare-covered services that require prior authorization under your Elderplan Plus Long-Term Care (HMO-POS D-SNP )plan. Your provider should contact us before scheduling any service on this list. If you are unsure whether a specific service requires authorization, call Member Services at 1-877-891-6447 (TTY: 711) before your appointment.
Prior authorization is never required for emergency care. If you have a medical emergency, call 911 or go to the nearest emergency room immediately. Emergency care is always covered and does not require plan approval.
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 are any questions about whether authorization is needed for a specific service or item before scheduling.
Cardiac Rehab Services
| Service | What you should know |
|---|---|
| Cardiac Rehabilitation | Covered at a $0 copay for members who meet Medicare Coverage criteria with a physician’s order |
| Intensive Cardiac Rehabilitation Services | Covered at a $0 copay for members meeting Medicare criteria with a doctor’s order |
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. |
Outpatient & Rehabilitation Services
| Service | What you should know |
|---|---|
| Physical therapy, occupational therapy, and speech/language pathology | Authorization is required in all outpatient settings. |
| Partial hospitalization services | Authorization is required for partial hospitalization behavioral health programs. |
| Intensive outpatient services (IOP) | 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 12 weeks 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 Computed Axial Tomography (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. |
| Diabetic Supplies | Authorization may be required. Diabetic Testing Strips and Blood Glucose Meters are limited to Abbott Diabetes Care and Ascensia manufacturers. Continuous Glucose Monitors (CGM) are limited to Freestyle Libre. |
| 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. |
| Home infusion therapy — Medicare Part B drugs | Authorization may be required for certain Medicare Part B drugs administered through home infusion. Step Therapy may be required. |
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). |
Other Health Care Professionals
| Service | What you should know |
|---|---|
| Nurse Practitioner or Physician Assistant | Prior authorization is only required if the Nurse Practitioner or Physician Assistant is conducting an in-home visit that is billed directly by them |
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.
- Your PCP or specialist contacts our Prior Authorization Department directly and submits the required clinical information.
We review the request and notify you and your provider of the decision in writing within the required timeframe:
- Standard request: Decision within 7 calendar days
- Urgent/expedited request: Decision within 72 hours, if waiting could seriously harm your health
If you need to request authorization, you have the right to do so on your own behalf. Call Member Services at 1-877-891-6447 (TTY: 711), and we will guide you through the process.
→ Getting Approval for Care — full details on the process, timeframes, and your rights if a request is denied
Looking for prescription drug prior authorization? That’s a different process. If you need prior authorization for a medication — not a medical service — that is handled separately through your Part D drug benefit. Visit the Getting Approval for Your Medications page for step-by-step instructions.