Medical Pre-Authorization Request Form (Page 2 of 2) in pdf

Coventry Health Care of Florida Pre-Authorization Rules

Authorizing Treatment for Members: Please refer to the Authorizing Treatment for Members section of the Provider Manual for additional information. Providers and

Hospitals shall use the Pre-Authorization Request Form found in the Forms Section of the Provider Manual or in the forms section of the website at

IMPORTANT: Members should refer to their Summary of Benefits or Evidence/Certificate of Coverage for information regarding their covered health care services.

Provider Type

Service/Procedure (regardless of place of treatment)

Ambulance Transport (non-emergency)

Automatic Implantable Cardioverter Defibrillator - (AICD)

IMRT

Air Ambulance (non-emergency)

Blepharoplasty

Laparoscopic Hysterectomy

Hospital Admission

Bone Growth Stimulators

Liquid Oxygen

Hospital Outpatient Services (all, includes

Breast Surgery for Benign Condition

Manipulation Under Anesthesia

diagnostic testing)

Clinitron Bed

MRA/MRI

Maternal Fetal Medicine

Cosmetic Surgery

Pain Management

Neuropsychology

CT/CTA/CCTA

Panniculectomy/Abdominoplasty

Non-participating Providers

Customized Wheelchairs

PET Scans

Oral Surgery

Diagnostic Nuclear Medicine & Nuclear Cardiology

Power Mobility Devices (power wheelchair and scooters)

Rehabilitation Facility Inpatient Admission

DME

Prosthetics/Braces/Orthotics

Reproductive Endocrinology

Echo Stress

Rehabilitation Therapies (PT, ST, OT)

Skilled Nursing Facility Admission

Enhanced External Counter Pulsation

Removal of Keloid/Lipomas

Vent/Sub-acute, Long-term Care Admission

Experimental/Investigational Services

Rhinoplasty/Septoplasty

Wound Care Centers (non-emergency)

Extracorporeal Shock Wave Therapy/Orthotripsy

Sclerotherapy for Varicose Veins

High Cost Radiology Services

Gastric Bypass/Banding

Sleep Studies

Genetic Testing

Spinal Fusion

Transplant Evaluations/Transplants

Home Health Services

Home Vents

Ultrasound, Pregnant Uterus, Transvaginal (76817)

Hospice Care

Uvulopalatopharyngoplasty

Hyperbaric Treatments

Wound Care (non-emergency)

Infertility Assessment/Treatment

Wound Vacs

Infusion* / Home/Office Drug-Replacement*

COMMERCIAL MEMBERS: Not required for members with a POS or PPO health benefits plan. However, if POS or PPO members do not obtain a prior authorization,

the amount covered by VISTA will be reduced by 20% or 50% depending on their specific health benefits plan

Clinical information will be required to substantiate request. The above list is subject to change.

The following is a list of ancillary providers that are to be used statewide for all lines of business (except as displayed below):

Specialty

Name

Phone #

Fax #

(800) 447-3725

National Imaging Associates, Inc. (NIA)

Web Address:

Diagnostic & High Cost Radiology Services

(800) 642-7821

Home Health Care

Univita Nursing Management

(888) 914-2201

(888) 914-2202 (except North Florida Healthy Kids)

Univita Specialty Infusion Pharmacy

(954) 217-6055

(954) 217-6062

Home Infusion/injectables

ICore

(866) 522-2469

(866) 522-2478

Home-Office Drugs/Drug Replacement

The ICore forms necessary to order the following are included in the Forms section of our Website at Drug Order for Home Use, Chemotherapy

Drug Replacement & Physician Office Medications.

The following is a quick reference of ancillary providers that can be used for West Florida:

Specialty/

Contact

Provider Name

County (ies) Serviced

Fax Number

Address

City

Zip

Service

number

O2 Solutions

DME/Resp Therapy Hillsborough; Pasco; Pinellas

727-934-3979

727-581-3618 1441 Savannah Ave, Ste B

Tarpon Springs

34689

Hernando; Hillsborough,

BayCare Home Care

800-940-5151

800-676-3128 8452 118th Ave

Largo

33773

DME/Resp Therapy

Pasco; Pinellas; Polk

Interim Health Care

Pinellas; Pasco; Hillsborough

727-535-4455

727-538-2002 4726 N Habana Ave # 203

Tampa

33614

Home Health

Hernando; Hillsborough,

BayCare Home Care

Home Health

800-940-5151

800-676-3127 8452 118th Ave

Largo

33773

Pasco; Pinellas; Polk

Palms Home Care

Hillsborough

813-872-8566

813-342-5274 6001 Webb Road

Tampa

33615

Home Health

Palms Home Care

Pinellas

727-384-0300

727-343-2472 5633 1st Avenue South

St. Petersburg

33707

Home Health

Advantage Homecare

Hillsborough

813-496-9619

813-290-9095 8606 Boulder Court

Tampa

33615

Home Health

Hernando; Hillsborough,

BayCare Home Care

Home Infusion

800-940-5151

800-676-3129 8452 118th Ave

Largo

33773

Pasco; Pinellas; Polk

Hernando; Hillsborough,

Prosthetics &

BayCare Home Care

800-940-5151

800-676-3130 8452 118th Ave

Largo

33773

Pasco; Pinellas

Orthotics

Reminder: In West & North Florida, DME and rehabilitation therapies should be pre-authorized through Coventry Health Care of Florida’s Authorization Department.

For South Florida, send requests for the following services to our contracted vendors:

Specialty

Name

Phone #

Fax #

DME

Florida Home Medical Equipment

(888) 914-2201

(888) 914-2202

County: Dade

Radiation Oncology/Therapeutic

County: Broward, Palm Beach,

Products: Commercial & Medicare

Oncology/Hematology/Oncology

Martin & St. Lucie

Product: Medicare

County: Dade, Broward, Palm

Cardiology

Beach, Martin & St. Lucie

Products: Medicare

Rehabilitation therapy is initiated by the PCP with a Referral to a participating therapist for one visit for assessment. The therapist will then obtain the authorization

from the Network for South Florida

Medical Pre-Authorization Request Form Page 2

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