Medicare - Affinity Health Plan
The following services require prior authorization for Medicare Only: Medical Services Requiring Prior Authorization TYPE OF SERVICE All Hospital Admissions All Skilled Nursing Facility Admissions All Long-Term Acute Care Admissions AS PER: Affinity Affinity Affinity CONTACT Affinity Affinity Affinity All Inpatient Mental Health Partial Hospital/Residential Mental Treatment Services after 20 visits Outpatient Mental Health and Substance Abuse Services after 20 visits All Out-of-Area services (all services not in Affinity Health Plan’s Medicare service area) (except for Emergency services as defined by Medicare Out-of-Network Services (except for Emergency services as defined by Medicare Affinity Affinity Affinity Affinity Beacon Beacon Beacon Affinity Affinity Affinity All hospital-based Ambulatory Surgeries (All Sterilization Surgeries require prior auth regardless of where performed and obtaining prior auth will require submission of patient consent form for the procedure(s) ) Occupational Therapy after first 10 visits– Affinity Affinity Affinity Affinity After th 3rd visit Physical and SpeechTherapy - Authorization is required after a combined total Affinity Affinity Non-Emergency Transportation (Metro area requires medical justification for taxi service) BENEFIT IS CARVED OUT FOR NEW YORK CITY AND ROCKLAND, ORANGE, AND WESTCHESTER COUNTIES Affinity Affinity All Home Health Care Services (Skilled and HHA services) Outpatient Procedures Requiring Authorization Pain Management Procedures: Spinal Fusion, Other Decompression Surgeries, Facet Injections, Epidural Injections (outpatient only), kyphoplasty, Vertebroplasty, Pain Infusion Pump (back and neck pain only) and Spinal Cord Stimulator. Affinity Affinity Affinity Affinity Home Infusion Services Affinity Affinity of 20 Physical Therapy and/or Speech-Language Pathology visits TYPE OF SERVICE Transplant Procedures Sleep Studies (facility settings) AS PER: Affinity Affinity CONTACT Affinity Affinity All DME rentals and all DME supply purchases exceeding $1000 in cost All prosthetics exceeding $1000 in cost Affinity Affinity Affinity Affinity All Medical supplies exceeding $1000 in cost Affinity Affinity Durable Medical Equipment Requiring Prior Authorization Imaging Services Requiring Prior Authorization PET scans MRI/MRA Catscans, Cardiac CT and SPECT Medicare Part B Drugs Affinity Affinity Affinity Affinity CareCore CareCore CareCore Affinity/Caremark Laboratory Services Requiring Prior Authorization Affinity Affinity
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