Services Not Requiring Prior Authorization
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Prior authorization is not required for the following services, and services may be obtained from any qualified in-network or out-of-network provider:
- Minor Consent Services.
- Therapeutic and elective pregnancy termination.
- Family planning, sexually transmitted infection (STI) diagnosis and treatment, HIV testing and counseling, and sexual assault services.
- Biomarker testing related to advanced or metastatic stage 3 or 4 cancer (must be FDA-approved).
Referral and prior authorization are not required for Comprehensive Prenatal Services Program (CPSP) services. Services may be obtained from any participating CPSP providers.
Other services that do not require prior authorization include:
- Certain services for American Indian members, including:
- An American Indian member can obtain covered services from an out-of-network Indian health care provider without requiring a referral from a network primary care provider (PCP) or prior authorization.
- Indian health care providers, whether in the Plan’s network or out-of-network, can provide referrals directly to network providers without a referral from a network PCP or prior authorization. An American Indian member may receive services from an out-of-network Indian health care provider even if there are in-network Indian health care providers available.
- Pregnancy care with in-network obstetrician.
- Preventive services.
- Services for emergency medical conditions.
- Specialist referral (initial referral to participating specialist).