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. See the Authorization List Code Reference companion document for details.

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 all lines of business except Florida Hospital 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.HFHP (4347).

Specialty Imaging, Echocardiograms, Sleep Studies and Positive Airway Pressure (PAP) Devices - Authorizations are processed by AIM Specialty Health (AIM). Submit requests to AIM or access clinical guidelines through their website at: aimspecialtyhealth.com

Spinal Procedures (surgeries, injections) - Effective 10/1/17, authorizations are processed by Palladian Health for all product lines except Adventist Health System and Rosen Employee Plans. For participating plans, submit requests to Palladian or access clinical guidelines through their website at palladianhealth.com.

All Other Authorization Requests - Submit to Health First Health Plans by faxing 1.855.328.0059.

Important Notices:

• Palladian Therapy Delay - 12/17
• Palladian Therapy Announcement - 11/17

Authorization List Documents:

• Medical Drug Authorization List - effective 1/1/18 - Reference list of codes for injectible and infusible medications
• Medical Drug Authorization List - effective 4/1/18 - Reference list of codes for injectible and infusible medications
• Authorization List - effective 1/1/18 - Items and services that require pre-certification
• Authorization List Codes - effective 1/1/18 - Reference list of codes for items and services included on the Authorization List
• Authorization List Codes (AIM Radiology Program)
• Authorization List Codes (AIM Echocardiography Program)
• Authorization List Codes (AIM Sleep Program)
• Authorization List Codes (Palladian Spinal Proedures)
• Authorization List Changes - effective 1/1/18 - Requirements that have changed since the last update

Authorization Request Forms:

• Medical Authorization Request Form
• Pharmacy Authorization Request Form
• Hospice Pharmacy Authorization Request Form

2018 Clinical Guidelines:

• Prior Authorization and Step Therapy Criteria (MA-PD)
• Prior Authorization and Step Therapy Criteria (MA-PD Employer Groups)
• Prior Authorization and Step Therapy Criteria (Commercial Metal - 5 Tier)
• Prior Authorization and Step Therapy Criteria (Commercial - 5 Tier)
• Prior Authorization and Step Therapy Criteria (Commercial - 3 Tier)

Other clinical guidelines are available through organizations responsible for administering the authorization process.

Last updated: 4/10/2018