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Referral, Notification and Authorization

    Overview (02-16)

    Referral Policy and Procedures (02-16)
    When a Referral is Not Required (03-16)

Referral Form
    Referral Form (10-15)

    Notification Policy (09-17)
    Elective Admission Notification (06-17)
    Emergent Department/Urgent Admission  
     Notification (06-17)
    NICU Notification Policy (02-17)
    NEW: Eff. beginning 09/01/2017: Non-Invasive  
     Airway Assist Devices (CPAP, APAP, and BiPAP)  
     and Related Sleep Therapy Supplies Notification  
    When a Notification is Not Required (05-17)

Authorization Policies
    Prior Authorization Policy (01-18)
    Behavioral Health Care Prior Authorization &  
     Notification (10-15)
    Dental and Oral Surgery Prior Authorization (01-12)
    Durable Medical Equipment Prior Authorization (09-17)
    New: Genetic and Molecular Diagnostic Testing  
     Prior Authorization (01-18)
    NEW: Hip/Knee/Shoulder Surgeries Prior  
     Authorization (09-17)
    Home Health Care Prior Authorization (01-12)
    Infertility Services Prior Authorization (01-14)
    Intra-Facility Transfer Prior Authorization (01-12)
    Medical Drug Management Prior Authorization (12-17)
    Medication Prior Authorization Program (01-18)
    Non-Participating Provider Prior Authorization (08-13)
    Outpatient Advanced Imaging Prior Authorization (12-17)
    Outpatient Rehabilitative Therapy Services Prior  
     Authorization Policy (01-18)
    Pre-Implantation Genetic Testing (PGT) Prior  
     Authorization Policy (6-14)
    Skilled Nursing Facility and Rehabilitation  
     Facility Authorization (08-17)
    Effective 09/01/2017: Sleep Studies/Sleep  
     Therapies Authorization (06-17)
    Spine Management & Prior Authorization (06-17)

Prior Authorization and Exception Request Forms
    Bariatric Surgery Prior Authorization Form (02-16)
    Cholecystectomy Authorization Form (01-18)
    Dental Hospital or Surgical Day Care  
     Authorization Form (09-15)
    Dental or Oral Surgery Procedures Authorization  
     Form (10-12)
    Extended Care Facility Fax Request Form (12-17)
    Pedi/Adult Formula Prior Authorization Request  
     Form (03-16)
    Hereditary Breast-Ovarian Cancers Prior  
     Authorization Form (12-15)
    Hyaluronate Preparations for OA of Knee Prior  
     Authorization Form (07-14)
    Hysterectomy Authorization Form (01-18)
    Implantable Neurostimulators Authorization Form (07-15)
    Infertility Services Prior Auth Request Form &  
     IUI/IVF Cycle Summary Forms (09-14)
    Outpatient Pulmonary Rehabilitation Request Form (08-12)
    Outpatient Rehabilitative Therapies Prior  
     Authorization Request Form (07-15)
    Pre-Implantation Genetic Testing (PGT) Prior  
     Authorization Form (6-14)
    Prosthesis Coverage Determination Prior  
     Authorization Form (06-11)
    Sinus Surgeries Authorization Form (02-16)
    NEW: Non-Emergent Ground Transportation Prior  
     Authorization Form (09-17)
    Urinary Incontinence Surgery Prior Authorization  
     Form (07-15)
    Varicose Veins Prior Authorization Form (6-14)

Medication Prior Authorization Request Forms
• Medical Drug Program (CVS Health—NovoLogix)
    Immune Modulating Drugs (04-16)
    Injectable/Infusible Drug Exception Request Form (05-14)

    Quick Reference Guide by Service & Product (01-18)

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Important Information About This Manual
Quick Reference Guide by Service & Product
Key Contacts