Providers: Authorizations
Certain items and services require prior authorization (pre-certification) to evaluate medical necessity and eligibility for coverage. See the current Authorization List to determine if prior authorization is required for general categories of services.
We use both internal and external resources in the authorization process. For the services listed below, the process is handled by the organizations indicated.
Behavioral Health - For services in 2021: For all lines of business except AdventHealth and Rosen TPA plans, authorizations are processed by Magellan Healthcare. Submit requests to Magellan through their website at magellanprovider.com or by calling 1-800-424-4347. For services in 2022: Small and Large Group commercial plans will continue to utilize Magellan Healthcare for behavioral health needs. For Medicare and Individual plans, behavioral health needs will be managed by Optum. Please visit the following sites for any authorization related needs through Optum: Individual plans Medicare plans
All Other Authorization Requests – We encourage participating providers to request authorization through the online provider portal. For certain services requested via the online portal, you will have an option to complete a questionnaire. The answers to this questionnaire may lead to an automatic approval. However, even if an automatic approval is not provided immediately, the information provided via the questionnaire will help Health First Health Plans reduce the review turnaround time.
Authorization List Documents:
2021
- Medical Drug Authorization List – Reference list of codes for injectable and infusible medications
- eviCore Medical Oncology Drug Authorization List – Items that require pre-certification
- Medical Prior Authorization List – Items and services that require pre-certification
- Medical Prior Authorization List Changes - Requirements that have changed since the last update
2022
- Medical Prior Authorization List (Small and Large Group Commercial Plans) Updated July 1, 2022
- Medical Prior Authorization List (Medicare and Individual Plans)
- Medical Prior Authorization List Changes (Small and Large Group Commercial Plans) Updated July 1, 2022
Authorization Request Forms:
2021
- Provider Prior Authorization Form
- Provider Request for Medicare Prescription Drug Coverage Determination
- Provider Dispute Form
2022
- Provider Prior Authorization Form (Small and Large Group Commercial Plans)
- Provider Prior Authorization Form (Medicare and Individual Plans)
- Provider Authorization Intake Form
- Provider Request for Medicare Prescription Drug Coverage Determination
- Provider Request for Prescription Drug Coverage Redetermination
- Prescription Claim Form (Medicare)
- Continuity and Transition of Care Guidelines
Formulary Prior Authorization Lists:
2021
- SunSaver: Prior Authorization | Step Therapy
- Employer Groups: Prior Authorization | Step Therapy
2022 - Coming Soon
For AdventHealth Employee Health Plan:
Only Applies for Services in 2021
- Medical Drug Authorization List – Reference list of codes for injectable and infusible medications
- eviCore Medical Oncology Drug Authorization List – Items that require pre-certification
- Medical Prior Authorization List - Items and services that require pre-certification
- Medical Prior Authorization List Changes - Requirements that have changed since the last update
- RxPlus Website
- Provider Prior Authorization Form
For Rosen Employee Plan: A referral from the PCP is needed for most services
Only Applies for Services in 2021
- Medical Drug Authorization List – Reference list of codes for injectable and infusible medications
- eviCore Medical Oncology Drug Authorization List – Items that require pre-certification
- Medical Prior Authorization List
- Medical Prior Authorization List Changes - Requirements that have changed since the last update
- Referral to Specialist
- Provider Prior Authorization Form
Other clinical guidelines are available through organizations responsible for administering the authorization process.