Outpatient Services
Outpatient Services Preauthorization
Some outpatient procedures, invasive diagnostic procedures, and other outpatient services require preauthorization through the SWHP Health Services Division. These authorizations will be handled through the SWHP Authorization forms process as a request to the Plan Medical Director(s) for individual case review and a coverage determination. Remember: For Members to receive full benefit of coverage under the terms of the Evidence of Coverage and/or Standard Plan Document, they should be receiving services from SWHP-approved physicians or providers. Guidelines for coverage of specific services are as outlined in this section. This list includes, but is not limited to:
- Any Out-of-Plan services
- Coronary CT Angiography
- Major Joint Replacements
- Spine Surgeries
- Level II Outpatient Cardiac Rehabilitation after initial 8 weeks
- Home Care Services (Includes Skilled Nursing, PT/OT/Speech, Social Services, Aides, etc.)
- Home Infusion Services
- Dental/Oral Surgery Procedures
- Laparoscopy (If for Infertility services)
- Laser Ophthalmologic Treatment, except for Retinal disease
- Physical Medicine and Rehabilitation
- Behavioral Health Services
- Psychiatric/Psychologic Testing
- Plastic Surgery Procedures
- PT/OT/Speech in Intermediate and/or Long-term Care Facilities
- Skilled Nursing Level of Care
- Work-up for potential organ transplantation