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  • Ingham Health Plan Prior Authorization

    Authorization request will be processed within 48 hours (excluding weekends and holidays). For questions contact 866-291-8691
  • ALL PROCEDURES/TESTS REQUIRE PRIOR AUTHORIZATION EXCEPT
    OFFICE VISITS, AND ROUTINE DIAGNOSTIC OUTPATIENT LAB AND
    RADIOLOGY SERVICES

    SERVICES MUST BE MEDICALLY NECESSARY
    ONLY OUTPATIENT SERVICES COVERED – NO INPATIENT SERVICES
    EMERGENCY DEPT SERVICES NOT COVERED

    *Chemotherapy services - Not Covered

    SERVICES THAT REQUIRE PRIOR AUTHORIZATION (PA) FOR PAYMENT

    SERVICES ADDITIONAL INFORMATION
    Infusion Services* Limited benefit
    Injection Medications* Limited benefit
    Ophthalmologic exams and testing Medically necessary – no vision services
    Physical Therapy 12 visits per year, add visits with PA
    Outpatient Surgeries  
    Radiation Therapy  
    Genetic testing  
    Reconstruction Surgery  
    Skin Procedures  
    Sleep Study  
    Vein Treatments & Surgery  
    Any service that could be considered cosmetic or not medically necessary  
    Unclassified procedure codes  
    Behavioral Health Continued Coverage When individual has continued need after exhausting the 15 visits of the limited coverage benefits and attempts have been made to refer the individual to other public resources

     

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  • BEHAVIORAL HEALTH SERVICES REQUIRING PRIOR AUTHORIZATION (PA) FOR PAYMENT AFTER 15 VISITS BY A BEHAVIORAL HEALTH SPECIALIST ARE EXHAUSTED:

      Code Brief Description
    Diagnostic or Psychiatric Evaluation   90791 Diagnostic Evaluation by Psychiatrist
    90792

    Psychiatric Diagnostic Evaluation with medication services

    Therapy (Substance Use)   G0396 Alcohol/Substance abuse Intervention (15-30 min)
    G0397 Alcohol/Substance Abuse Intervention (>30 min)
    Therapy (Mental Illness)    90832 Psychotherapy with Pt (30 min)
    90834 Psychotherapy with Pt (45 min)
    90837 Psychotherapy with Pt (60 min)
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  • DISCLAIMER:

    • This health plan is not insurance. Plan benefits are limited.
    • Authorization is for specific CPT/HCPCS indicated.
    • Authorization is not a guarantee of payment.
    • Reimbursement for services rendered is subject to:-Member's coverage and eligibility on the date of service.- Service(s) rendered are performed within effective date range of authorization.
    • Providers must comply with Medicaid requirements.
    • Authorizations expire on Dec 31 of the calendar year in which service was authorized, unless otherwise indicated.

    If you have questions regarding this authorization, you may contact us at 1-866-291-8691 or www.ihpmi.org

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