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Prior Authorizations

Prior Authorizations

Prior Authorization Guide

Prior Authorization Guide (Specialty Drugs)

Lighthouse PA Form

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:

  • Medical
  • Surgical
  • NICU
  • Notification required within twenty-four (24) hours of admission or next business day.
  • Clinical updates required with continued stay

Admissions:

  • Elective Procedures/Surgery
  • LTAC, Rehabilitation, SNF
  • Observation Stays Extending Beyond 24 Hours
  • Radiology Procedures Requiring Inpatient or Observation
  • All Bariatric Procedures
  • All Transplants, excluding cornea
  • All elective admissions
  • Admission to any long-term acute care, rehabilitation or skilled nursing facility
  • Observation Stays Extending Beyond 24 hours
Transplants Require authorization for the initial evalution
OB Services
  • Induction of labor- if prior to thirty-nine (39) weeks gestation
  • OB ultrasound over two (2) per pregnancy
  • Stays over two (2) days for Vaginal delivery
  • Stays over four (4) days for Cesarean delivery
  • Termination of pregnancy
  • Scheduled C-Section
Services in Outpatient Hospital Facility
  • Outpatient surgery
  • Cardiac Cath
  • Colonoscopy
  • EGD
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.

  • Private duty nursing for children age twenty (20) or younger
  • Personal care services for children age twenty (20) or younger

Clinical updates required with continued review; incorporate review requirements during review process

Intensive Cardiac and Pulmonary Rehabilitation Services

  • Inpatient
  • Outpatient
Home Infusion / IVT Determined by Coastal Care Options
Outpatient Therapy

Physical / Occupational / Speech Therapies

  • Prior authorization after initial evaluation
Chiropractic Services  
Advanced Imaging:
  • CT/CTA
  • MRI/MRA
  • PET/SPECT
  • Nuclear Medicine Studies

Exclusions:

Imaging rendered in the following settings DOES NOT require prior authorization:

  • Emergency department
  • Inpatient setting
  • Observation unit

(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)
  • Inpatient
  • Outpatient
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