Prior Authorizations
Medical Policy and Procedure Updates
Prior Authorization Guide (Specialty Drugs)
**All non-participating provider requests require authorization regardless of service.**
Authorization requirements
The services listed below require Prior Authorization except where noted otherwise:
Inpatient Acute Hospital Admissions:
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Admissions:
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Transplants | Require authorization for the initial evalution |
OB Services |
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Services in Outpatient Hospital Facility |
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Dialysis | Authorization valid for 1 year of dialysis treatments |
Outpatient Bariatric Procedures | |
Home Health Services | Determined by Coastal Care Services, Inc. |
Private Duty Nursing |
Determined by Coastal Care Services, Inc.
Clinical updates required with continued review; incorporate review requirements during review process |
Intensive Cardiac and Pulmonary Rehabilitation Services
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Home Infusion / IVT | Determined by Coastal Care Options |
Outpatient Therapy |
Physical / Occupational / Speech Therapies
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Chiropractic Services | |
Advanced Imaging: |
Exclusions: Imaging rendered in the following settings DOES NOT require prior authorization:
(Contact number provided, CPT code list include - not carved out) |
Durable Medical Equipment (DME)/External Prosthetic Appliances (EPA) and Supplies |
Determined by Coastal Care Services, Inc. Orthotics/Prosthetics >$500 |
High Dollar Medications | Medications administered in office setting, otherwise through Pharmacy benefit. >$1000 |
All Potentially Cosmetic Surgery | |
Any Experimental / Investigational | |
Pain Management; Outpatient | |
All non-participating providers (All OON services) |
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Sleep studies | Facility based only |
Molecular Diagnostics Testing (DNA Testing) | |
Behavioral Health | Determined by Access Behavioral Health |
Pharmacy | See PDL |
Transportation/Transfers** |
Non-emergent Ground Medical Transport Air Medical Transport |
Dental Procedures | Those services that fall under the medical benefit (e.g. Orthognathic surgery) |
*All out-of-network physicians and hospital and ancillary requests require prior authorization.
**Note: OneCall Transportation may require medical necessity review.
All Lighthouse participating providers are required to obtain prior authorization from the Plan’s Utilization Management (UM) department for inpatient services and specified outpatient services. Failure to submit a request for authorization may result in a denial.
Because of frequent changes in enrollee’s eligibility for Medicaid coverage, providers should verify continued eligibility via our website or by calling Provider Services at 844-243-5181.
Utilization Management
The Utilization Management department is available Monday through Friday from 8:00 a.m. to 7:00 p.m. (EST), 7:00 a.m. to 6:00 p.m. (CST), except holidays. All requests for authorization of services may be received during these hours of operation. After business hours or on holidays, a provider can either fax the request or can call and leave a message and a representative will return the call the next business day.
Utilization Department Contact Numbers
Department | Phone | Fax |
General Number Initial Inpatient Outpatient |
844-824-8846 | 888-522-6490 |
Concurrent Review | 844-824-8846 | 888-522-6490 |
Retrospective Review | 844-824-8846 | 888-522-6490 |
Home Health | 855-481-0505 | 855-481-0606 |
Home Infusion | 855-481-0505 | 855-481-0606 |
DME | 855-481-0505 | 855-481-0606 |
Important Phone Numbers
Transportation
OneCall (Non-Emergent)
Toll Free Phone: 1-877-358-3529
Website: www.onecallhealth.com/members
Fax: 1-844-418-0531
Vision
ICARE Health Solutions
Toll Free Phone: 1-855-373-7627
Fax: 1-305-675-8195
Website: www.myicarehealth.com
Email: info@myicarehealth.com
Behavioral Health
Access Behavioral Health
Toll Free Phone: 1-800-342-3222 (24/7)
Website: www.abhfl.org
Fax: 1-850-469-3661
Nurse Advice Line
Health Dialog
Phone: (844) 865-7921 (24/7)
referral@healthdialog.com
Over-the-counter-supplies
OTCHS (CVS)
Phone: (833) 331-1571
www.lighthouse.otchs.com
Laboratory
Quest Diagnostics
Phone: (866) 697-8378
www.questdiagnostics.com
DME/Home Health/Infusion Pharmacy
Coastal Care Services, Inc.
Phone: (855) 481-0505 (24/7)
(855) 481-0606
www.ccsi.care/providers
Provider Portal: http://web.ccsi.care