NY Manual
SHP Manual

New York Provider Manual
XI Pre-Authorization Guidelines | XII Clinical Practice Guidelines

Appendix XI-B — Preauthorization Guidelines – Leaf Plan

 
ABA Treatment for Autism Spectrum Disorder
Preauthorization Required
Assistive Device for Autism Spectrum Disorder
Preauthorization Required
Advanced Imaging Services – Freestanding/Outpatient
Care Core
Preauthorization Required
All Out-of-Network Services
Preauthorization Required
Ambulatory Surgery Services
Preauthorization Required
Cardiac and Pulmonary Rehabilitation
Preauthorization Required
Chiropractic Services
Please refer to ASH
Cosmetic Services
Preauthorization Required
Dialysis
Preauthorization Required
DME and Breast Pump Rental
Preauthorization Required
EMG/Nerve Conduction Study
Preauthorization Required
Habilitation Services – Physical, Occupational, and Speech Therapy
Preauthorization Required
Hearing Aid and Cochlear Implants
Preauthorization Required
Home Health Care
Preauthorization Required
Hospice Care – Inpatient and Outpatient
Preauthorization Required
Infertility Services
Preauthorization Required
Inpatient Hospital Services and Facility
Preauthorization Required
Rehabilitation Services (Physical, Occupational, and Speech Therapy) – Inpatient and Outpatient
Preauthorization Required
Insulin Pump
Preauthorization Required
Interruption of Pregnancy (Abortion)
Preauthorization Required
Mental Health and Substance Use Services – Admissions and the following outpatient services:
ECT, Neuropsychological Testing, Partial Hospital Program, Intensive Outpatient Treatment, and Day Treatment require preauthorization. 
 Authorization for traditional in-network outpatient behavioral health services provided by Healthfirst rroviders is not required.
Preauthorization Required
Non-emergency Ambulance Services
Preauthorization Required
Outpatient Hospital Services and Surgery
Preauthorization Required
Prosthetic (External and Internal)
Preauthorization Required
Skilled Nursing Facility
Preauthorization Required
Transplant
Preauthorization Required

Preauthorization is not a guarantee of payment. Payment by Healthfirst for services provided is contingent upon the member’s active membership in Healthfirst at the time of service or when treatment was rendered. Policies are subject to change.

·     For preauthorization for the services listed above or to notify Healthfirst of an admission, contact the Medical Management department at 1-888-394-4327.
·     For advance imaging and radiology preauthorization, please contact CareCore at 1-877-773-6964.
·     For preauthorization of surgical procedures of the eye, please contact Block Vision at 1-877-773-6964.
·     For information on chiropractic services, please contact ASH at 1-800-972-4226.
·     For pharmacy authorizations, please contact CVS Caremark at 1-800-294-5979.