Referrals and Prior Authorizations

Prior authorization, also known as precertification, is a process of reviewing certain medical, surgical or behavioral health services to ensure medical necessity and appropriateness of care prior to services being rendered. This process requires either your doctor/provider or you to get approval from Capital Health Plan before receiving specific items and services. The review also includes a determination of whether the service being requested is a covered benefit under your benefit plan. If the specific item or service is a covered benefit in your plan (refer to your member handbook for specific details), CHP reviews the request and your benefits using criteria based on approved clinical evidence. CHP uses written criteria based on sound clinical evidence to evaluate the medical appropriateness of health care services.

Authorizations are only required for certain services. Your physician will submit authorization/precertification requests electronically, by telephone, or in writing by fax or mail. If approved, an authorization number is then generated by CHP and is available to you via CHPConnect. If the requested service is not authorized, the member and doctor/provider are notified in writing with the specific reasons for the denial and appeal rights.

These criteria are objective and based on current clinical and medical evidence and applied with consideration of individual needs and characteristics (e.g., age, comorbidities, prior treatment, and complications), and the availability of services within the local delivery system.

• All requests for prior authorization are processed and a determination is communicated within 15 calendar days of receipt of all necessary information. Determination can be sooner if your health is in serious jeopardy or if your pain cannot be adequately controlled while a decision is being made; or if your life, health, or ability to regain maximum function is in serious jeopardy.
• If prior authorization is needed for a service, consult your PCP, the ordering doctor, or Member Services. Your PCP will manage permissions (prior authorizations) for medical services and prescription drugs. However, it is also your responsibility to ensure that the authorization is in place before receiving the item or service.

You can review your Summary of Benefits and Coverage by scanning the QR code on the back of your CHP card or by logging into CHPConnect. After logging into CHPConnect, select “Benefits and Eligibility” from the left menu to view your Summary of Benefits and Member Handbook. You can also use the transparency tool on the left side menu of CHPConnect to help estimate your plan costs.

Authorization numbers are not required for the services below; these can be completed with a referral or an order from your primary care physician or specialist.

• Most office visits and office-based procedures for local network participating practitioners [1]
• Ambulatory Surgical Center procedures performed at local network participating facilities
• Outpatient hospital procedures and services (excluding Wound Care and Hyperbaric Oxygen treatment, which continue to require an authorization) performed at local network participating hospitals
• Participating out-of-area practitioners and OP facilities (i.e. University of Florida Health a.k.a. Shands/Gainesville)
• Outpatient services at participating out-of-area practitioners and facilities, (i.e. University of Florida Health a.k.a. Shands)
• Tallahassee Memorial Center for Pain Management (a.k.a Tallahassee Neurology Pain Management Facility)
• Mammography (screening and/or diagnostic) or ultrasound to detect abnormality in the breast, including those performed at a local participating hospital
• Mastectomy bras and prosthetics as allowed under the member’s group benefit package at local participating doctors and providers
• Blood and blood products received in a local participating outpatient hospital facility
• OB labor checks at a local participating outpatient hospital facility
• Ostomy supplies obtained from Medical Care Products
• Certain DME items and oxygen obtained from American Home Patient Care (in the service area), Barnes Healthcare Services, and Desloge Home Oxygen & Medical Equipment
• Sleep studies performed at Tallahassee Memorial Outpatient Sleep Center
• Hospice home-based services
• Dialysis services [2]
• Physical therapy and occupational therapy obtained from TMH Outpatient Rehabilitative Services and the Center for Orthopedic and Sports Physical Therapy
• Most outpatient diagnostic imaging at local participating radiology locations (TDI, THI, Radiology Associates, Stand-Up MRI of Tallahassee)
• Intensive outpatient substance abuse treatment with local participating network practitioners
• Services rendered in a medical emergency
• Laboratory services performed through the LabCorp network (physicians and hospitals must use LabCorp for routine lab work).

Authorization numbers are required for the following services.

• All inpatient services
• Outpatient hospital-based services for Wound Care and Hyperbaric Oxygen treatment (HBO)
• All non-participating practitioners or facilities in or out of CHP’s service area
• Nutritional counseling when not provided by the TMH Diabetic Center
• All services related to the mouth and/or teeth
• Services that may be investigational or outside the realm of accepted mainstream medical care
• All procedures or surgeries that have CHP clinical criteria require review and an authorization at any location. See a listing of Capital Health Plan Clinical Criteria.

The following are just a few of the services that have clinical criteria and require a review and a prior authorization. For a full list please click here.

• Genetic testing
• Back (lumbar) and neck (cervical) surgery, also known as spinal surgery
• Transcranial Magnetic Stimulation
• Implantable hearing devices
• Certain Durable Medical Equipment (DME), such as: External Insulin Infusion Pumps & Supplies, Continuous Glucose Monitoring, and Power Wheelchairs
• Certain medications when obtained under the medical benefit, refer to the Medication Center for more information

For questions about referrals or prior authorizations, to request a paper copy of your Summary of Benefits and Coverage, or to talk to a representative, please call member services at (850) 383-3311.