When is prior authorization needed?
Security Health Plan requires prior authorization for some medical services or equipment. While a provider will generally make these requests and submit the necessary forms, it is a member’s responsibility to make sure the process is followed. A health care provider may contact Security Health Plan to determine whether a prior authorization is required for a member’s service or medical equipment by calling our Provider Assistance Line at 1-800-548-1224. Click here to view a list of services that require prior authorization.
Please note: The Security Health Plan prior authorization requirements apply regardless of whether or not we are your primary or secondary coverage. If the claim will eventually be billed to Security Health Plan (whether we are your primary or secondary insurer), prior authorization will be required for payment.
Prior authorization requirements apply to all plans from Security Health Plan.
Prior authorization requirements apply to services requested directly from Security Health Plan and to those requested from vendors contracted by Security Health Plan, such as, but not limited to, eviCore, NaviHealth, Magellan or Northwood for Security Health Plan members.
Prior authorization should be sought for workers’ compensation/liability cases to avoid denials in the event workers’ compensation/liability coverage is denied or exhausted.
If you are being seen for an injury believed to be work-related and covered by workers’ compensation, the services should be prior authorized at the same time the service is provided. This is to ensure coverage in the event the workers’ compensation claim is denied.
Prior authorizations from Northwood, Inc.
All services for durable medical equipment, prosthetic-orthotic services and amino acid formula will require prior authorization from Northwood, Inc.
Security Health Plan has partnered with Northwood, Inc., to manage the following services. Your provider will work with Northwood to ensure that authorizations are in place for products and services you receive.
- durable medical equipment
- prosthetic-orthotic services
- amino acid formula
Pharmacy prior authorizations
Medical benefit drugs
Home infusion drugs
Skilled nursing services that require prior authorization
acute rehabilitation admission
long-term acute care admission
skilled nursing facility admission
Services that require prior authorization from eviCore
For all high-end imaging, radiation oncology services, cardiac imaging, heart catheterization and sleep management services you will need to work with your provider to receive prior authorization from eviCore healthcare.
For high-end imaging
Fax an eviCore request form (available online) to 1-888-693-3210
For radiation oncology
For cardiac imaging, heart catheterization and sleep management services
Services that require prior authorization
- Abnormal vascular lesions (port wine stain)
- Air ambulance transport
- Amino acids
- Autologous cultured chondrocytes
- Back surgeries at all levels
- Breast reconstruction post mastectomy not related to cancer
- Carpal tunnel surgery
- Chemotherapy infusions
- Clinical trials
- Cosmetic and reconstructive surgery
- Durable medical equipment
- Electroconvulsive therapy (ECT)
- Elective inpatient admission including acute medical, behavioral health and surgical
- Elective outpatient procedures such as, but not limited to: carpal tunnel surgery, knee arthroscopy, back surgeries at all levels
- Enteral feeding
- Eyelid and brow repair procedures
- Femoroacetabular impingement surgery
- Genetic testing
- Hearing aids for members over 18 years of age
- High end imaging (CT, PET, MRI)
- High end imaging (cardiac imaging) and elective heart catheterization
- Hip surgery
- Home health services including but not limited to skilled nursing, physical therapy, occupational therapy, speech therapy
- Hyaluronic acid
- Infuse bone graft
- Interventional pain management
- Intravenous iron therapy
- Knee surgery
- Long term acute care admission
- Non-network provider request
- Non-emergent ambulance transport
- Oral appliance for obstructive sleep apnea
- Outpatient therapy treatment (occupational therapy, physical therapy, speech therapy)
- Pharmaceuticals - specialty medications
- Radiation oncology therapy
- Reduction mammoplasty
- Second opinion
- Skilled nursing facility admissions
- Skin substitute
- Sleep management
- Spinal cord stimulation
- Swing bed admission
- Technologies not commonly accepted as standard of care
- Vagus nerve stimulation