Saturday, December 4, 2010

ASC procedures required authorization and referral

Prior Authorization and Referral Requirements

Certain procedures require prior authorization. Please refer to the ASC
Procedures List in Appendix I. A “Y” in the PA column on the list indicates
surgical procedures that require prior approval. Payment will not be made for
these procedures unless authorized prior to the service being rendered.
When filing claims for recipients enrolled in the Patient 1st Program, refer to
Chapter 39, Patient 1st, to determine whether your services require a referral
from the Primary Medical Provider (PMP).

All requests for prior approval must document medical necessity and be signed
by the physician. Requests should be sent to HP, Attention Prior Authorization,
P.O. Box 244032, Montgomery, Alabama 36124-4032.
The prior authorization number issued must be listed on the UB-04 claim form
when billing for the prior authorization service.

It is the responsibility of the physician to obtain prior authorization for any
outpatient surgical procedure to be performed in an outpatient hospital or
ambulatory surgical center

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