Services Requiring Authorization

Keystone First - CHIP offers our providers access to Medical Authorizations for electronic authorization inquiries and submission. The Medical Authorizations portal is accessed through NaviNet*, located on the Workflows menu. 

In addition to submitting and inquiring on existing authorizations, you will also be able to:

• Verify if No Authorization is Required.
• Receive Auto Approvals, in some circumstances.
• Submit Amended Authorization. 
• Attach supplemental documentation.
• Sign up for in-app status change notifications directly from the health plan. 
• Access a multi-payer Authorization log. 
• Submit inpatient concurrent reviews online if you have Health Information Exchange (HIE) capabilities. (Fax is no longer required.)
• Review inpatient admission notifications and provide supporting clinical documentation.

*If the NaviNet portal is down, prior authorization requests may be addressed by calling 1-877-486-2447. 

The following is a list of services requiring prior authorization review for medical necessity and place of service.

• All elective (scheduled) inpatient hospital admissions, medical and surgical including rehabilitation.
• All elective transfers for inpatient and/or outpatient services between acute care facilities.
• All elective transplant evaluations and procedures.
• All miscellaneous/unlisted or not otherwise specified codes.
• All services that may be considered experimental and/or investigational.
• Any service(s) performed by non-participating or non-contracted practitioners or providers, unless the service is an emergency service.
• Cosmetic procedures regardless of treatment setting to include, but not limited to, the following:
  • Reduction mammoplasty
  • Gastroplasty
  • Ligation and stripping of veins
  • Rhinoplasty
• Durable Medical Equipment (DME)
  • DME monthly rental items regardless of the per month cost/charge.
  • Home Accessibility DME Equipment (refer to the DME section of the manual for complete details).
  • Purchase of all items greater than $750
  • Select wheelchair components
  • The purchase of all wheelchairs (motorized and manual) regardless of cost per item
• Elective/non-emergent Air Ambulance Transportation.
• Elective termination of pregnancy – Refer to the Termination of Pregnancy section of the Provider Manual for complete details.
• Enterals
  • Required when greater than $350 per month
• Genetic Testing.
• Home Health Services
  • Prior authorization is not required for up to 18 home visits per modality per benefit period including:
    • Skilled nursing visits by a RN or LPN
    • Home Health Aide visits
    • Physical Therapy; Occupational Therapy and Speech Therapy
    • Home Respiratory Therapy; Mechanical Ventilation Care; Stoma Care and Maintenance
    • Colostomy and Cystectomy
  • The duration of services may not exceed a 60-day period.
  • The enrollee must be re-evaluated every 60 days.
• Home Oxygen Therapy
  • All requests for oxygen and oxygen equipment require authorization.
  • Initial authorization is for 6 months and reauthorizations require an updated prescription with current oxygen saturation level (refer to the Durable Medical Equipment section for complete requirements and details).
• Incontinence Supplies
  • Age 3 and older.
  • Greater than $750.
• Injectables.
• Neurological Psychological Testing.
• Pain management services performed in a Short Procedure Unit (SPU) or Ambulatory Surgery Unit (either hospital-based or freestanding)
  • Pain management services not on the Medical Assistance fee schedule performed in a physician’s office.
• Private Duty Nursing
• Radiology - The following outpatient services require prior authorization by Keystone First - CHIP’s radiology benefits vendor, Evolent.
  • Positron Emission Tomography (PET)
  • Magnetic Resonance Imaging (MRI)/Magnetic Resonance Angiography (MRA)
  • Nuclear Cardiology /MPI
  • Computed Axial Tomography (CT/CTA/CCTA)
  • Emergency room, Observation Care and inpatient imaging procedures do not require Prior Authorization.
  • Refer to the Radiology Services section in the Provider Manual for prior authorization details.
• Select gastroenterology services.
• Skilled Nursing Facility admission for alternate levels of care in:
  • A facility, either free-standing or part of a hospital that is of lesser intensity than that received in a hospital.

• The following services require prior authorization:
  • Autism Services / ABA
  • Mental Health Inpatient services
  • Mental Health Partial Hospitalization Services
  • Mental Health Intensive Outpatient Treatment
  • Outpatient Services:  Electroconvulsive therapy
  • Psychological/Neuropsychological Testing
  • Substance Use Intensive Outpatient Services
  • Substance Use Inpatient Services
  • Substance Use Partial Hospitalization Services
• Providers must call Keystone First – CHIP at 1-877-244-7124 to request telephonic prior authorization for Mental Health Inpatient, Mental Health Partial Hospitalization, and Mental Health Intensive Outpatient Programs (IOP), Substance Use Inpatient, and Substance Use Partial Hospitalization, and Substance Use Intensive Outpatient Programs (IOP).  
• Providers can request prior authorization for all other covered services requiring prior authorization via the Keystone First – CHIP NaviNet Provider Portal.
• Services Not Requiring a Referral (Enrollee Self-Referral)
  • Mental Health Outpatient Services
  • Substance Use Outpatient Services
  • Mental Health Intensive Outpatient Treatment
  • Substance Use Intensive Outpatient Services
  • Emergency Services

Select Prescription Medications. For information on which prescription drugs that require authorization, the Keystone First - CHIP Formulary can be found in the Provider Center at www.keystonefirstchip.com.