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