Items and Services Requiring Prior Authorizations

Authorization numbers are not required for the following; the service 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, hyperbaric oxygen treatment, and observation lasting more than 48 hours, 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 and Nemours Children's Clinics)
  • Tallahassee Memorial Center for Pain Management (a.k.a. Tallahassee Neurology Pain Management Facility)
  • Mammography 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 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
  • DME 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
  • Home Health Care services
  • Hospice home-based services
  • DaVita dialysis services [2]
  • Physical therapy and occupational therapy obtained from TMH outpatient Rehabilitative Services and the Center for Orthopedic and Sports Physical Therapy (up to benefit limits)
  • Most outpatient diagnostic imaging at local participating radiology locations
  • Intensive outpatient substance abuse treatment with local participating network practitioners
  • Services rendered in a medical emergency
  • LabCorp network lab. Local outpatient physicians and hospitals should use LabCorp for routine lab work.

Authorization numbers are required for the following:

  • All inpatient services
  • Outpatient hospital-based services for wound care, hyperbaric oxygen treatment (HBO), and observation lasting more than 48 hours
  • All non-participating practitioners or facilities in or out of CHP's service area
  • All services related to the mouth and/or teeth
  • Speech therapy
  • Applied Behavioral Analysis (ABA) therapy
  • Nutritional counseling
  • Kelly Lang, M.D., practicing at TMH Bariatric Center
  • Services that may be investigational or outside the realm of accepted mainstream medical care
  • All procedures or surgery that has CHP clinical criteria requires review and an authorization at any location. See a listing of Capital Health Plan Clinical Criteria on the Medical Policies page.

The following are just a few of the services that have clinical criteria and require a review and a prior authorization:

  • Genetic testing
  • Back (lumbar) and neck (cervical) MRIs
  • Back (lumbar) and neck (cervical) surgery (also known as spinal surgery)
  • Hip Arthroplasties (also known as total hip replacement)
  • 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.

[1] Contact Capital Health Plan’s Member Services Department for further information on which local participating practitioner services still require an authorization

[2] Dialysis services received outside of Capital Health Plan’s service area may necessitate receiving services from a facility other than DaVita – you should work with your local DaVita facility to coordinate these services prior to leaving the service area.

[3] You and your primary care physician have access to Capital Health Plan’s utilization management clinical criteria through CHPConnect. You may also request a list of Capital Health Plan’s clinical criteria by contacting the Member Services Department.