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Service Name Prior Auth Reqd? PA Form Notification Reqd? Notify. Form Threshold Product List. Yes, notification within 24 hours.

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Service Name Prior Auth Reqd? PA Form Notification Reqd? Notify. Form Threshold Product List

ACUPUNCTURE

Acupuncture is covered for chronic pain. Chronic pain is defined as pain with duration of at least six consecutive months.

Yes, after threshold's met Authorization Request Medical Surgical Services Form No 40 units per year (unit=15 min)

All Products

CHEMICAL DEPENDENCY SERVICES

Detox - Inpatient No Assessors - CD Request Worksheet; Full Rule 25 Assessment

Treating Facility - (both Input and Oupt treatment) - CD Admission Form for all Levels of Care/ SCHA CD Complexities Grid

Yes, notification within 24 hours.

Assessors - CD Request Worksheet

None All Products

Detox - Outpatient Not a covered benefit through SCHA

No No None All Products

Hospital-based inpatient residential program

Yes Assessors - CD Request Worksheet; Full Rule 25 Assessment

Treating Facility - (both Input and Oupt treatment) - CD Admission Form for all Levels of Care/ SCHA CD Complexities Grid (at time of admission and if complexity changes); Rule 25 Assessment & Placement Summary when request continued stay

No None All Products

Medication Assisted Treatment (including Suboxone, Methadone, and injectable)

Yes Assessors- CD Request Worksheet; Full Rule 25 Assessment

Treating Facility- (both Input and Outpt treatment) - CD Admission Form for all Levels of Care/SCHA CD Complexities Grid (at time of admission and if complexity changes); Minnesota Outpt MH/CD Authorization; Rule 25 Assessment & Placement Summary when request continued stay

No None All Products

*Payment is determined at the time the claim is received and is subject to health plan exclusions and out -of-network benefit limitations. Plan coverage must be in effect for the member at the time the service(s) is

rendered.

*Service considered experimental or investigational must be approved by Medicare to be a covered service.

*Thresholds stating per year and per calendar year

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Non-hospital based inpatient residential program (Facilities licensed to provide room and board services only) Low, Moderate, High Intensity

Yes Assessors - CD Request Worksheet; Full Rule 25 Assessment

Treating Facility - (both Input and Outpt treatment) - CD Admission Form for all Levels of Care/SHCA CD Complexities grid (at time of admission and if

complexity changes); Rule 25 Assessment & Placement Summary when request continued stay

No None All Products

Non-hospital based inpatient residential program (Residentially licensed chemical dependency provider, eg Rule 31) Low, Moderate, High Intensity

Yes Assessors - CD Request Worksheet; Full Rule 25 Assessment

Treating Facility - (both Input and Outpt treatment) - CD Admission Form for all Levels of Care/SHCA CD Complexities grid (at time of admission and if

complexity changes); Rule 25 Assessment & Placement Summary when request continued stay

No None All Products

Outpatient Treatment Yes Assessors - CD Request Worksheet; Full Rule 25 Assessment

Treating Facility - (both Input and Outpt treatment) - CD Admission Form for all Levels of Care/SHCA CD Complexities grid (at time of admission and if

complexity changes); Rule 25 Assessment & Placement Summary when request continued stay

No None All Products

Rule 25 Assessment Yes, to request CD placement

Government CD Request Worksheet, FULL Rule 25 Assessment

No None All Products

DURABLE MEDICAL EQUIPMENT AND RELATED SUPPLIES

Apnea monitors No No None All Products

Baclofen pumps No No None All Products

Communication devices Yes Authorization Request Medical Surgical Services Form No None All Products

Continuous Glucose Monitoring systems

Yes Authorization Request Medical Surgical Services Form No None All Products

Custom wheelchairs (power) and Power operated vehicle (POV)

Yes Authorization Request Medical Surgical Services Form Note: No authorization is needed for repairs or items needed to maintain the function of the POV is under $750. This includes batteries, battery chargers, tires, arm rests, general use cushions, and anti-tip devices.

No None All Products

Equipment greater or equal to $750 or any rental item rented for greater than 4 months. (Rental is paid up to purchase price.)

Yes Authorization Request Medical Surgical Services Form No None All Products

Insulin pumps No

Authorization Request Medical Surgical Services Form

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Orthotics or Prosthetics over $750

Yes Authorization Request Medical Surgical Services Form No None All Products

Yes Authorization Request Medical Surgical Services Form Yes None PMAP and MnCare

Yes, for initial use only Authorization Request Medical Surgical Services Form Yes None MSC+, MSHO, AbilityCare, SNBC with Medicare, SNBC Medicaid Only Oxygen, CPAP Yes, after 4 months of

use.

Authorization Request Medical Surgical Services Form No None All Products

Positioning seats Yes Authorization Request Medical Surgical Services Form No None All Products

Specialty hospital beds Yes Authorization Request Medical Surgical Services Form No None All Products

Specialty pressure mattress

Yes Authorization Request Medical Surgical Services Form No None All Products

Unlisted code E1399 over $500 (Misc. DME)

Yes Authorization Request Medical Surgical Services Form No None All Products

Unlisted code K0108 over $500 (Misc. wheelchair accessories)

Yes Authorization Request Medical Surgical Services Form No None All Products

Vest percussors Yes Authorization Request Medical Surgical Services Form No None All Products

HEALTH AND SAFETY EQUIPMENT AND SERVICES

Health and Safety

Equipment and Services

Yes. Care Coordinator submits PA

SCC Health & Safety Request Form v.1 No $300 per year MSHO

HEARING AID

Hearing Aide, new and replacement

Yes More than 2

replacements in 5 years requires PA

Authorization Request Medical Surgical Services Form No 2 replacements in a 5-year period

All Products Oxygen, excluding oxygen

supplies, nebulizers, BI PAP and ventilators

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HOME HEALTH SERVICES - MEDICARE

Skilled nursing care,

Therapy (PT, OT, ST); Medical social services; and Medical Supplies

No Yes CMS-485 or

Physician's Order for the skilled services

None MSHO and AbilityCare

HOME CARE SERVICES - MEDICAL ASSISTANCE AND DD, CAC, CADI, BI WAIVER

Home Health Aide Yes, auth must be

obtained from county case mgr

DHS-5841 Recommendation for Authorization of MA Home Care Services

No None Member must have a DD, CAC, CADI, BI

waiver. PMAP, MSC+, MSHO, AbilityCare, SNBC with Medicare, SNBC with Medicaid Only

Personal Care Assistant (PCA)

Yes, auth must be obtained from county case mgr

DHS-5841 Recommendation for Authorization of MA Home Care Services

No None Member must have a DD, CAC, CADI, BI

waiver. PMAP, MSC+, MSHO Private Duty Nursing Yes, auth must be

obtained from county case mgr

DHS-5841 Recommendation for Authorization of MA Home Care Services

No None Member must have a DD, CAC, CADI, BI

waiver. PMAP, MSC+, MSHO Skilled Nurse Visits Yes, auth must be

obtained from county case mgr.

DHS-5841 Recommendation for Authorization of MA Home Care Services

No None Member must have a DD, CAC, CADI, BI

waiver. PMAP, MSC+, MSHO, AbilityCare, SNBC with Medicare, SNBC with Medicaid Only

HOME CARE SERVICES - MEDICAL ASSISTANCE AND ELDERLY WAIVER

Home Health Aide Yes, auth must be

obtained from county case mgr.

SCHA Waiver Notification Form must be submitted by the member's care coordinator to SCHA.

No None MSC+, MSHO, Member must have EW

Personal Care Assistant (PCA)

Yes, auth must be obtained from county case mgr.

SCHA Waiver Notification Form must be submitted by the member's care coordinator to SCHA.

No None MSC+, MSHO, Member must have EW

Private Duty Nursing Yes, auth must be obtained from county case mgr.

SCHA Waiver Notification Form must be submitted by the member's care coordinator to SCHA.

No None MSC+, MSHO, Member must have EW

Skilled Nurse Visits Yes, auth must be obtained from county case mgr.

SCHA Waiver Notification Form must be submitted by the member's care coordinator to SCHA.

No None MSC+, MSHO, Member must have EW

HOME CARE SERVICES - MEDICAL ASSISTANCE NON-WAIVER

Home Health Aide Yes, after the 9th visit per

calendar year.

Home Care Fax Form (DHS-4074) or Authorization Request Medical Surgical Services Form

No None PMAP, MSC+, MSHO, AbilityCare, SNBC

with Medicare, SNBC with Medicaid Only Member does NOT have a waiver Personal Care Assistant

(PCA)

Yes Personal Care Assistance Assessment and Service Plan (DHS-3244)

No None PMAP, MSC+. MSHO-

Member does NOT have a waiver

Private Duty Nursing Yes MA Private Duty Nursing Assessment - (DHS-4071A) No None PMAP, MSC+. MSHO-

Member does NOT have a waiver Skilled Nurse Visits Yes, after the 9th visit per

calendar year

Home Care Fax Form (DHS-4074) or Authorization Request Medical Surgical Services Form

No None PMAP, MSC+, MSHO, AbilityCare, SNBC

with Medicare, SNBC with Medicaid Only - Member does NOT have a waiver

HOSPICE CARE

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Hospice Care No Yes Hospice Notification Worksheet

None All Products

HOSPITAL CARE - INPATIENT

Continued Stays for More

than 2 days

Yes Authorization Request Medical Surgical Services Form Yes- Within 24 hours of admission SCHA requests a discharge notification within 24 hours of discharge. Inpatient Notification Form for both admission and discharge

All Products

Emergent Medical Hospital Admission

No Yes- Within 24 hours

of admission SCHA requests a discharge notification within 24 hours of discharge. Inpatient Notification Form for both admission and discharge

None All Products

Non-Emergent Medical Hospital Admission

Yes Authorization Request Medical Surgical Services Form Yes- Within 24 hours of admission SCHA requests a discharge notification within 24 hours of discharge. Inpatient Notification Form for both admission and discharge

None

All Products

Swing Bed - Refer to Nursing Home Services on this PA grid

MENTAL HEALTH SERVICES

ACT (Assertive

Community Treatment)

No Yes Government

Notification Form

None; See Note F All Products Acute Inpatient Mental

Health

Yes MH/CD Worksheet - Prior Authorization and Notification Form

Yes - Within 24 hours of admission

MH/CD Worksheet - Prior Authorization and Notification Form

None All Products

Adult Crisis Residential Services

Yes, after 5 days. MN Universal Outpatient Mental Health/Chemical Dependency Authorization Form

Yes, upon admission. Government Notification Form

None All Products

Adult Day Treatment (Behavioral Health Day Treatment

Yes - See Note E below. MN Universal Outpatient Mental Health/Chemical Dependency Authorization Form

No Max 15 hrs per week;

may not obtain authorization for more day treatment hours in a week; 115 hours per calendar yr without authorization

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ARMHS (Adult Rehabilitative Mental Health Services)

Yes, after threshold is met and also if provided concurrently with ACT services..

MN Universal Outpatient Mental Health/Chemical Dependency Authorization Form

Yes, at the start of care

Government Notification Form

1200 Units cumulative, All ARMHS codes combined per year

All Products

Certified Peer Specialist Yes, after threshold is met.

MN Universal Outpatient Mental Health/Chemical Dependency Authorization Form

No 300 hrs per calendar

year combined total by Level I, II, and peer services in a group setting.

All Products

CTSS (Children's Therapeutic Services and Support)

Behavioral Health Day Treatment

Yes, after threshold is met.

MN Universal Outpatient Mental Health/Chemical Dependency Authorization Form

No Minimum 2 hrs daily &

Max 3 hrs, may not obtain auth'n for more day treatment hrs in a day; Max 15 hrs/ week; may not obtain auth'n for more day treatment hrs in a week; 150 hrs per calendar yr; request auth'n for additional medically necessary services

PMAP

CTSS (Children's Therapeutic Services and Support)

Family Therapy

Yes, after threshold is met.

MN Universal Outpatient Mental Health/Chemical Dependency Authorization Form

No 26 sessions per year;

cumulative for any combination of group therapy

PMAP

CTSS (Children's Therapeutic Services and Support)

Group Therapy

Yes, after threshold is met.

MN Universal Outpatient Mental Health/Chemical Dependency Authorization Form

No 52 sessions per year

cumulative for any combination of group psychotherapy

PMAP

CTSS (Children's Therapeutic Services and Support)

Multifamily Group

Yes, after threshold is met.

MN Universal Outpatient Mental Health/Chemical Dependency Authorization Form

No 10 sessions per year PMAP

CTSS (Children's Therapeutic Services and Support)

Therapy

Yes, after threshold is met.

MN Universal Outpatient Mental Health/Chemical Dependency Authorization Form

No 200 cumulative hours

per calendar year (units vary by 30, 45, or 60 minutes)

PMAP

CTSS (Children's Therapeutic Services and Support) Skills Training & Development

Yes, after threshold is met.

MN Universal Outpatient Mental Health/Chemical Dependency Authorization Form

No 200 cumulative hours

per calendar year for any combination of psychotherapy, skills training, crisis assistance, therapeutic components of preschool program and Mental Health Behavioral Aide services.

(7)

DBT (Dialectic Behavioral Therapy ) - Individual DBT Therapy

Yes MH/CD Worksheet - Prior Authorization and Notification Form

No Up to 26 hours (104

units) per 6 moths (unit=15 min), See note E

All Products

DBT (Dialectic Behavioral Therapy) Group DBT Skills Training

Yes MH/CD Worksheet - Prior Authorization and Notification Form

No Up to 78 hours (312

units) per 6 month (unit =15 min), See note E

All Products

Diagnostic Assessment Yes, after threshold is met.

MH/CD Worksheet - Prior Authorization and Notification Form

No 2 sessions

4 max per year See note D below

All Products Eating Disorders - Inpatient Treatment *Go to Non-Emergent Medical Hospital Admission

Yes Authorization Request Medical Surgical Services Form Yes, within 24 hours of admission

Inpatient Notification Form

None All Products

Eating Disorders - Outpatient

Yes MN Universal Outpatient Mental Health/Chemical Dependency Authorization Form

Yes MN Universal Outpatient Mental Health/Chemical Dependency Authorization Form All Products

IMD (Institute of Mental Disease)

Yes MH/CD Worksheet - Prior Authorization and Notification Form Yes MH/CD Dependency Admission Worksheet All Products Intensive Outpatient Mental Health Treatment

Yes, after threshold is met.

MN Universal Outpatient Mental Health/Chemical Dependency Authorization Form

Yes MN Universal Outpatient Mental Health/Chemical Dependency Authorization Form

10 days per episode All Products

IRTS (Intensive Residential Treatment Services)

Yes, after threshold is met.

MH/CD Dependency Admission Worksheet No 90 days per episode -

See Note C below

All Products

MH-TCM (Mental Health Targeted Case Management)

Yes MH TCM Eligibility Determination Form; DA; Verification of SPMI/SED

Yes, within 60 days of completed DA or request for MH-TCM services. Fax to SCHA @ 507-431-6329 MH TCM Eligibility Determination Form and supporting documentation

None All Products

Neuropsychological Testing

Yes, after threshold is met.

Psychological Testing Form No 7 hours

(15 hrs max per person per year)

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Partial Hospitalization Yes, after threshold is met.

MN Universal Outpatient Mental Health/Chemical Dependency Authorization Form

Yes MN Universal Outpatient Mental Health/Chemical Dependency Authorization Form

10 days per episode All Products

Psychological Testing Yes, after threshold is met.

Psychological Testing Form No 4 hours

(8 hours max per person per year)

All Products

Psychotherapy - Family Yes, after threshold is met.

MN Universal Outpatient Mental Health/Chemical Dependency Authorization Form

No 26 sessions of family psychotherapy per calendar year; 10 sessions of multiple family group psychotherapy per calendar year All Products

Psychotherapy - Group Yes, after threshold is met.

MN Universal Outpatient Mental Health/Chemical Dependency Authorization Form

No 52 sessions per

calendar year, cumulative. See Note G.

All Products

Psychotherapy - Individual Yes, after threshold is met.

MN Universal Outpatient Mental Health/Chemical Dependency Authorization Form

No 26 hours per calendar

year cumulative. See Note G.

All Products

Rule 5 Children's' Residential Treatment Services

Yes MH/CD Dependency Admission Worksheet Yes MH/CD

Dependency Admission Worksheet

None PMAP, MNCare

NURSING HOME SERVICES

NF - Custodial Care No Yes - Within 24 hours

of admission

Nursing Home Communications Form

None MSC+, MSHO, AbilityCare, SNBC with Medicare, SNBC with Medicaid Only SNF - Intensive Service

Days

Yes Nursing Home Communication Form Yes - Within 24 hours

of admission

Nursing Home Communications Form

None MSHO, AbilityCare, SNBC with

Medicare, SNBC with Medicaid Only

SNF or NF - Private Room Yes Nursing Home Communication Form Yes - Within 24 hours of admission

Nursing Home Communications Form

None MSHO, AbilityCare, SNBC with

Medicare, SNBC with Medicaid Only, MSC+

SNF - Skilled Care Days Yes Nursing Home Communication Form Yes - Within 24 hours of admission

Nursing Home Communications Form

None MSHO, AbilityCare

Swing Bed Yes - See note K Inpatient Notification Form No None MSHO, AbilityCare, SNBC with Medicaid

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OUT-OF-NETWORK SERVICES

Out-of-Network

Provider/Service

Yes, if services are indicated as needing a PA on the PA Grid

Authorization Request Medical Surgical Services Form Yes None All Products

PUBLIC HEALTH NURSE VISITS

Public Health Nurse Visits No No None All Products

REHABILITATION

Acute Care Rehab Yes Authorization Request Medical Surgical Services Form No None All Products

Outpatient Therapies - Physical Therapy, Occupational Therapy, Respiratory Therapy, Speech Therapy - No maintenance (custodial) therapies for members over 20 yrs old.

No No None All Products

SURGERY

Circumcision - Routine Circumcisions are not a covered benefit.

Yes Authorization Request Medical Surgical Services Form No None All Products

Miscellaneous Yes - See Note A below Authorization Request Medical Surgical Services Form No None All Products

Oral Surgery, Maxillofacial Surgery, or

Uvulopalatopharyngoplast y (UPPP), Alveoplasty

Yes Authorization Request Medical Surgical Services Form No None All Products

Reconstructive procedures and/or potentially cosmetic procedures

Yes - See note B below Authorization Request Medical Surgical Services Form No None All Products

Spinal Surgeries - Arthrodesis, Lumbar Fusion, or X-Stop

Yes Authorization Request Medical Surgical Services Form No None All Products

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VISION

Lenses with special tints, coatings, or no glare

Yes Authorization Request Medical Surgical Services Form None All Products

Vision Therapy Yes Authorization Request Medical Surgical Services Form No 1 exam & 1 weekly

therapy session per 6 month period

All Products

MISCELLANEOUS

Growth Hormones Yes MN Uniform Formulary Exception Form No None All Products

Medications administered in Physician's office costing greater than or equal to $750. See note J.

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Botox See note I.

Yes Authorization Request Medical Surgical Services Form No All Products

Nutritional Supplements Yes, after the threshold is met

Authorization Request Medical Surgical Services Form No 1040 units per month All Products

Specialty Formula Yes Authorization Request Medical Surgical Services Form No All Products

Restricted Recipients No Yes, all referrals to a

specialist require notification from the Primary Care Clinic

Manage Care Referral Form

None All Products

If you have a question about a service not listed, call MMSI Provider Services at 800-995-4543

Benefits are subject to eligibility at the time service is rendered.

Authorization Forms can be found at www.mnscha.org under Provider Resources tab and then forms

Authorization Requests: MMSI Health Services Fax: 888-889-7822

Benefit Plan Provisions: Call Provider Services 800-995-4543

Verify Member Eligibility and Primary Care Location: Provider Services Center 800-995-4543

Prime Therapeutics Utilization Management: 800-693-6651 Fax 800-693-6703

Note A

- such as, but not limited to: Implantable ventricular assist systems and artificial hearts, lung volume reduction , vargus ner ve stimulation, deep brain stimulation, varicose vein treatment, bone stimulators

Note B

- such as, but not limited to: Brow Lifts, Panniculectomy, scar excision/revision, reduction mammoplasty or mastoplexy, bariatr ic surgery, subcutaneous injections to change contours, suction lipectomy,

tattooing or tattoo removal, septoplasty and rhinoseptoplasty, salabrasions, skin peels

Note C

- Maximum 90 days per episode. Readmission within 15 days counts towards 90 day limit. Request authorization for more than 90 days. Service limitations apply when providing IRTS and other concurrent

services. Please see SCHA Mental Health Provider Manual for specifics.

Note D

- Authorization is required to exceed 2 sessions per calendar year, cumulative for 90791 and 90792. Maximum of 4 sessions per c alendar year. Provider cannot bill both 90791 and 90792 for same recipient -

choose one or the other. Interactive complexity add-on 90785 may be used with 90791 ofr 90792. See SCHA Mental Health Provider Manual for specifics.

Note E

- Authorization 1. After threshold; or 2. When receiving concurrent DBT services (regardless of 115hrs was met; or 3. Authoriza tion is required to provide concurrent partial hospitalization or adult day tx and

residential crisis stabilization services concurrently.

Note F

- Service limitations apply when providing ACT and other concurrent services. Please see SCHA Mental Health Provider Manual for specifics.

Note G

- Interactive complexity may be used with some psychotherapy codes. Please see SCHS Mental Health Provider Manual for specific s.

Note H

- Do not provide psychotherapy concurrently with interactive psychotherapy. Interactive complexity may be used in certain situa tions. See SCHA Mental Health Provider Manual for specifics.

Note I

- Per DHS Botox cannot be used for the treatment of migraines.

Note J

- Synagis does not require a prior authorization.

Note K -

Not a covered benefit for PMAP, MN Care, MSC+. Contact DHS provider services for further assistance. For SNBC members wi th Medicare elsewhere contact Medicare.

Note L-

Ability Care refers to SCHA's dual integreated plan. SCHA covers both Medicare and Medicaid. SNBC with Medicare refers to those members who have only their Medicaid coverage through SCHA and

Medicare elsewhere. SNBC Medicaid Only refers to those members who only have Medicaid eligibility and have full Medicaid b enefits through SCHA.

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