PRE-AUTHORIZATION POLICY
The pre-authorization process involves the following:
- Verify Member’s current eligibility information from the State of Michigan.
- Review the service requested based upon the available benefit or the Member.
- Evaluate medical necessity of services based on the type of service, level of care, and/or network availability as mandated by Pro Care's Medicaid contract.
- Conduct accurate claims adjudication based on the entry of network, units/days, level of care, and/or benefit authorized.
Facility Services
- Inpatient Admission
- Outpatient Surgery
- Inpatient Rehab Admission
- Sub acute Admission
- Skilled Nursing Admission
- Inpatient Hospice
- Transplants, including evaluation
Testing and donor search
Office Services
- Nutritional Counseling
- Pain Management
- Second/Third Medical Opinions
- Vision Therapy Evaluation and Treatment
- Health Education
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Outpatient Services
- Diagnostic procedures such as, but not limited to, colonoscopy, cardiac stress test, MRI, CT scans, Amniocentesis, PET scans
- Durable Medical Equipment and Orthotic and Medical Supply Items
- Chemo Therapy
- Infertility Studies
- Chronic Pain Management
- Chiropractic Services
- Non-Emergency Transportation
- Injectables
- Physical, Occupational and Speech Therapy
Home Care Services
- Home Nursing Service
- Home Health Service
- Hospice Care
- Infusion Therapy
- Any service provided in the home
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Misc:
All Non-Participating Provider Referrals
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