Prior Authorization Requirements
Prior authorization is not required for emergency or urgent care.
To request prior authorization, please submit your request via fax or phone:
- Referrals and Authorization Department at 1-888-477-4663
- Outpatient Authorizations Fax: 1-315-870-7788
- Inpatient Admissions Fax: 1-315-870-7788
A Prior Authorization is not a guarantee of payment; Payment is subject to member eligibility and benefits at the time of service.
All services that require prior authorization from Nascentia Health Plus must be authorized before the service is delivered. Nascentia Health Plus evaluates prior authorization requests based on medical necessity, medical appropriateness, and benefit limits. Claims for services for which prior authorization is required, but not obtained by the provider, will be denied payment.
The Medical Management Department will notify you of their decision by secure email, mail or phone.
|Benefit||Details||Nascentia Health Plus MAP||Nascentia Health Plus Institutional - I-SNP||Nascentia Health Plus Dual - D-SNP|
|Is Prior Authorization Required?|
|Inpatient Hospital Acute||
|Skilled Nursing Facility||
|Cardiac & Pulmonary Rehabilitation Therapy||N||N||N|
|Home Health Services||
|Physician Specialist Services||
|Mental Health Specialty Services||N||N||N|
|Other Health Care Services||N||N||N|
|PT & SP Services||N||N||N|
|Opioid treatment Services||N||N||N|
|Outpatient Diagnostic Procedures/Labs- Base 4||
|Outpatient Diagnostic Procedures/Radiation||
|Outpatient Hospital Services||
|Ambulatory Surgery Center Servicess||Y||N||Y|
|Outpatient substance abuse||N||N||N|
|Outpatient blood services||N||N||N|
|Ambulance Services (non emergent)||
|Durable Medical Equipment||
|Diabetic Supplies & Service||N||N||N|
|Medicare Zero Dollar Preventative Services||N||N||N|
|Kidney Disease Education||N||N||N|
|Other Medicare Covered Preventative Services||
|Medicare Part B Prescription Drugs||
Download the Prior Authorization Requirements (PDF) document.
Download the Prior Authorization Request Form (PDF) document.