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)
- 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
- 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:
- Please download and review the Medical Services that Require Prior Authorization list.
- 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:
- Please download and review the Medical Services that Require Prior Authorization list.
- 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 temporarily needed while outside of Capital Health Plan’s service area may necessitate receiving services from a facility other than DaVita or Frescenius Kidney Care- you should work with your local dialysis 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.