Arizona

Prior Authorization Requirements Health Net Access, Inc. 

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Effective: July 1, 2016

The following services, procedures and equipment are subject to prior authorization requirements (unless noted as notification required only). When faxing a request, please attach pertinent medical records, treatment plans, test results, and evidence of conservative treatment to support the medical appropriateness of the request. All services are subject to benefit plan coverage limitations, members must be eligible, and medical necessity must exist for any plan benefit to be a covered service irrespective of whether or not prior authorization is required.

Providers should refer to Health Net Access prior authorization limitations and exclusions on page 4 for additional information. Unless noted differently, all services listed below require prior authorization from Health Net Access. Refer to page 5 for submission information and prior authorization contacts.

INPATIENT SERVICES1 COMMENTS Acute rehabilitation facility Behavioral health or detoxification applies to dual eligible members only*

includes hospital, psychiatric hospital, subacute facility, and residential treatment center or related bed holds

Hospice facility Hospital facility Newborns – births (including stillborn and unexpected deaths) within 12 hours of delivery

Providers must complete and submit the Newborn Reporting Form, in conjunction with the Health Net prior authorization request, by secure fax to the Health Net Hospital Notification Unit.

The Newborn Reporting Form is available in the Forms section of the Provider Library on the Health Net provider website at provider.healthnet.com.

Nursing facility/skilled nursing facility Observation services Notification required only if less than 24 hours. If greater than 24 hours,

authorization is required; contact the Health Net Hospital Notification Unit Urgent/emergent admission

Notification required only as soon as possible, but no later than 24 hours or by the next business day; contact the Health Net Hospital Notification Unit

*Dual eligible members are members who are eligible and enrolled for coverage through Medicare and Medicaid. Dual eligible members have access to behavioral services through Health Net Access. Regional Behavioral Health Authorities (RBHAs), and/or the Tribal/Regional Behavioral Health Authorities (T/RBHAs) will continue to administer the benefits for children, individuals with serious mental illness (SMI), and those who are not dually eligible for Medicare and Medicaid.   

Arizona Health Net Access 

Effective: July 1, 2016 Page 2 of 5

OUTPATIENT PROCEDURES, SERVICES OR EQUIPMENT COMMENTS All non-contracted and out-of-state services Ambulance Applies to non-emergency fixed wing air transportation Back/spinal surgery Includes laminotomy, diskectomy, vertebroplasty, and nucleoplasty Bariatric-related services Surgical procedure Blepharoplasty Surgical procedure Breast implants removal Surgical procedure Breast reconstruction Surgical procedure Breast reduction and augmentation Surgical procedure Chondrocyte Implants Cleft palate reconstructive surgery, including dental and orthodontic services

Surgical procedure

Clinical trials Cosmetic services, evaluation and procedure Custom orthotics Dental Dental procedure covered by medical benefit requires PA. Contact Dental

Benefit Providers for all other dental services. Dermatology

Procedure Including but not limited to: chemical exfoliation and electrolysis dermabrasion/chemical peel laser treatment skin injections and implants

Electroconvulsive therapy (ECT) Applies to dual eligible members only* Genetic testing   Durable medical equipment (DME) (see pre-authorization tool for guidance) 

Enteral/parenteral/medical foods services and supplies  Experimental/investigational services and new technologies  Includes, but is not limited to, those listed in the Investigational Procedures

List located on the Health Net provider website at provider.healthnet.com > View our Medical Policies > Investigational Procedure List.

Home health services Hospice/palliative care  Hyperbaric oxygen therapy  Intensity modulated radiation therapy (IMRT) 

*Dual eligible members are members who are eligible and enrolled for coverage through Medicare and Medicaid. Dual eligible members have access to behavioral services through Health Net Access. Regional Behavioral Health Authorities (RBHAs), and/or the Tribal/Regional Behavioral Health Authorities (T/RBHAs) will continue to administer the benefits for children, individuals with serious mental illness (SMI), and those who are not dually eligible for Medicare and Medicaid.    

Arizona Health Net Access 

Effective: July 1, 2016 Page 3 of 5

OUTPATIENT PROCEDURES, SERVICES OR EQUIPMENT, CONTINUED

COMMENTS

Maternity  

Prior authorization is required at the time of first prenatal visit. The authorization will apply to the total obstetrical care date range Providers are required to identify risk factors by completing a comprehensive tool that covers psychosocial, nutritional, medical, and educational factors (such as the American Congress of Obstetricians and Gynecologists (ACOG) or Mutual Insurance Company of Arizona (MICA) assessment tools).

Providers are required to submit the risk factor assessment, such as the ACOG or MICA assessment tool, in conjunction with the Health Net Request for Prior Authorization form, when requesting prior authorization. o The Health Net Access Request for Prior Authorization form available

in the Forms section of the Health Net Access website at www.healthnetaccess.com.

Neuro or spinal cord stimulators   Neuropsych testing  Orthognathic procedures (including TMJ treatment) Surgical procedure Outpatient diagnostic procedures

Contact eviCore healthcare for the following procedures: computed tomography (CT) magnetic resonance angiography (MRA) scans magnetic resonance imaging (MRI) scans nuclear cardiac imaging procedures positron emission tomography (PET)

Outpatient physical, occupational, and speech therapy Rehabilitative and habilitative services Perinatology referral and care Notification required only Posterior tibial neuro stimulation/pelvic floor stimulation Surgical procedure Pregnancy termination Surgical procedure Prosthetics (see pre-authorization tool for guidance) Proton beam therapy Psychological testing Applies to dual eligible members only* Rhinoplasty Surgical procedure Septoplasty Surgical procedure Stereotactic radiosurgery and stereotactic body radiotherapy (SBRT) Sterilization Surgical procedure Transplant-related services, including evaluation Treatment of varicose veins Surgical procedure Uvulopalatopharyngoplasty (UPPP) and laser-assisted UPPP Surgical procedure X-Stop Surgical procedure

*Dual eligible members are members who are eligible and enrolled for coverage through Medicare and Medicaid. Dual eligible members have access to behavioral services through Health Net Access. Regional Behavioral Health Authorities (RBHAs), and/or the Tribal/Regional Behavioral Health Authorities (T/RBHAs) will continue to administer the benefits for children, individuals with serious mental illness (SMI), and those who are not dually eligible for Medicare and Medicaid.   

Arizona Health Net Access 

Effective: July 1, 2016 Page 4 of 5

OUTPATIENT PHARMACEUTICALS (SUBMITTED UNDER MEDICAL BENEFIT)

COMMENTS

Hemophilia factors Prior authorization required from HNPS Self-injectables Prior authorization required from HNPS Actemra® Aldurazyme® Aralast® Aranesp® Benlysta® Botox® Cerezyme® Cinryze® Cosentyx® Dysport® Entyvio™* Fabrazyme® Flolan® Glassia™ H.P. Acthar® Gel

Ilaris® Immune globulin

Krystexxa® Lemtrada® Lucentis® Lumizyme® Makena™ Myobloc® Myozyme® Naglazyme® Nplate® Orencia® Prolastin® Provenge® Remicade®

Remodulin® Rituxan® (non-

oncology only) Simponi® Aria™ Soliris® Stelara® Synagis® Tysabri® Ventavis® Vpriv™ Xeomin® Xiaflex® Xolair® Zemaira®

Prior authorization required from HNPS Immune globulin examples: intravenous immunoglobulin (IVIG), Hizentra®, HYQVIA

*Dual eligible members are members who are eligible and enrolled for coverage through Medicare and Medicaid. Dual eligible members have access to behavioral services through Health Net Access. Regional Behavioral Health Authorities (RBHAs), and/or the Tribal/Regional Behavioral Health Authorities (T/RBHAs) will continue to administer the benefits for children, individuals with serious mental illness (SMI), and those who are not dually eligible for Medicare and Medicaid.

Prior Authorization Limitations and Exclusions Listed below are prior authorization limitations and exclusions, and sensitive, confidential or other services that do not require prior authorization for Health Net Access members.

Authorizations for Children’s Rehabilitation Services (CRS)-eligible conditions for members under age 21 and enrolled in CRS require prior authorization from CRS. Contact CRS at 1-866-275-5776 or by email at CRS_SpecialNeeds@uhc.com

Routine laboratory services must be performed at participating facilities Authorization requests for behavioral health and substance abuse services for children, individuals with serious mental illness (SMI) and those

who are not dually eligible for Medicare and Medicaid must be referred to RBHAs/TRBHAs. If coordination assistance with RBHAs/TRBHAs is needed, contact the Health Net Access Member Services Department. For dual eligible non-SMI members, behavioral health and substance abuse services are excluded.

Emergency room (ER) services after stabilization of an emergency medical condition or when the medical screening exam (MSE) does not demonstrate an emergency medical condition are subject to review by Health Net and may not be paid

Arizona Health Net Access 

Effective: July 1, 2016 Page 5 of 5

Prior Authorization Contacts Listed below are contact numbers for requesting prior authorization via telephone and fax. Also included is contact information for commonly requested Health Net and other departments.

CONTACT INFORMATION Prior authorization request

1-888-926-1736; fax: 1-855-764-8513 Health Net Access Prior Authorization Request available in the Forms section

on the Health Net Access provider website at www.healthnetaccess.com Behavioral health Coordinated by Mercy Maricopa Integrated Care: www.mercymaricopa.org;

1-602-586-1841 or 1-800-564-5465 (TDD/TTY: 711) Behavioral health (inpatient behavioral health or detoxification; ECT; and psychological testing) for dual eligible members only*

1-888-926-1736; fax: 1-855-764-8513

Dental Benefit Providers

1-855-866-2620

Health Net Dental Dental Benefit Providers AZ Medicaid PO Box 306 Milwaukee, WI 53201

Eligibility and benefits provider.healthnet.com or 1-888-788-4408 Health Net Access Member Services Department 1-888-788-4408 (TTD/TTY: (888) 788-4872) Health Net Hospital Notification Unit

1-888-926-1736; fax: 1-855-764-8513 After hours and weekends: 1-888-926-1736

Medicaid general information – Arizona Health Care Cost Containment System (AHCCCS)

www.azahcccs.gov

Health Net Pharmaceutical Services (HNPS) 1-800-410-6565; fax: 1-800-977-4170 eviCore healthcare for listed outpatient diagnostic procedures 1-888-693-3211; fax: 1-888-693-3210; www.medsolutionsonline.com

*Dual eligible members are members who are eligible and enrolled for coverage through Medicare and Medicaid. Dual eligible members have access to behavioral services through Health Net Access. Regional Behavioral Health Authorities (RBHAs), and/or the Tribal/Regional Behavioral Health Authorities (T/RBHAs) will continue to administer the benefits for children, individuals with serious mental illness (SMI), and those who are not dually eligible for Medicare and Medicaid.