Prior Authorizations

Prior Authorization Information  

2/24/22: Our fax lines are back and operational.

For all services requiring prior authorization, Providers must send requests to the UM Department via fax to (202) 721-7190 or via email at UM@hschealth.org.  All non-urgent requests will be responded to within 14 calendar days.  For issues requiring urgent attention, contact the UM Department at (202) 721-7162 to submit your request. All urgent requests will be responded to within 72 hours.

Note: Emergency and Stabilization Services (ER Services) never require a prior authorization request regardless of the network status of practitioner, providers or facility providing ER Services.

Out of Network services always require prior authorization.  If a provider elects to refer an HSCSN enrollee to non-participating (out-of-network) specialist for any reason, this request must receive prior authorization from HSCSN before the HSCSN enrollee accesses the services.

The following services require notification:

Inpatient admission within 24 hours of admission or the next business day

Newborn Deliveries within 24 hours of delivery or the next business day

DME/DMS Delivery notification within 24 hours of delivery or the next business day

The following services DO NOT REQUIRE prior authorization when performed by an in-network provider:

• Primary Care Office Visits
• Specialty Office Visits
• Women Well Care Visits (including Depo-Provera shots)
• Vision Services (the first pair of standard eyeglasses do not require prior authorization)
• Labs and Radiology Services (including x-rays, sonograms, MRIs, CT and PET Scans)
• Outpatient Mental Health Services (psychiatric evaluations, substance abuse, medication management, and therapy services [individual, group, family]

The following services DO REQUIRE prior authorization when performed by an in-network provider:

• Applied Behavior Analysis (ABA) therapy
• Outpatient Rehabilitative Therapies:
  • Speech-Language Therapy
  • Physical Therapy
  • Occupational Therapy
  • Other: Acupuncture, Massage Therapy, Chiropractic Treatment, etc.
• Home Health Care Services:
  • Skilled Nursing Visits
  • Private-Duty Nursing (shifts of nursing care)
  • Personal Care Aide Services / Home Health Aides
  • PT, OT, ST
• Durable Medical Equipment (DME) and Disposable Medical Supplies (DMS)
• Home Modifications
• Respite Care
• Psychological /Neuropsychological evaluation/testing
• Elective Procedures and Surgeries
• Intensive Day Treatment / Partial Hospitalization / Day Rehabilitation Programs
• Admission or Transfer to subacute facilities:
  • Rehabilitation facilities
  • Skilled Nursing Facilities (SNF)
  • Psychiatric Residential Treatment Facilities (PRTF)
  • Intermediate Care Facilities for Intellectually and Developmentally Disabled (ICF-IDD)
• All Out-of-Network Services
• Admission to hospital for acute care requires concurrent review (they need to notify HSCSN within 24 hours and submit clinical documents within 48 hours of admission)