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Prior Approval Information

Disclaimer

Would you like to check the status of a Pending Or Existing Precert ?

Important Notice for ARBenefits:

The Arkansas State and Public School Employees groups utilize Health Advantage coverage policies which can be found on healthadvantage-hmo.com. Once there, click on the section titled view your ARKANSAS STATE OR PUBLIC SCHOOL PLANS here. Some services may require pre-certification/pre-authorization or be limited. For this group, you may view the Summary Plan Description at arbenefits.org for a full list of covered services and exclusions as well as pre-certification requirements.

Pre-certification / Prior authorization

Pre-certification or Prior authorization is a review prior to the time a specified procedure is scheduled. This review consists of checking clinical documentation to verify the medical necessity for the procedure. A prior authorization is required for each different procedure, even if those procedures are performed on the same day. Failure to obtain prior authorization will result in denial of the claim. If a provider fails to pre-certify a hospital admission or outpatient procedure, the member is not subject to any penalty for non-certification. It is your responsibility to verify or make certain the procedure has been pre-certified.

For Behavioral Health/Substance Abuse, precertification will need to be obtained by Lucet at 1-877-982-8295.

High Tech Radiology services will need to be precertified by Carelon at 1-866-688-1449.

All other medical services that require prior authorization/precertification will need to be obtained by calling Health Advantage at 1-800-482-8416.

For your convenience, below is a list of medical services, durable medical equipment, radiology and medical procedures that requires pre-certification/ prior authorizations as of 1/2/18:

Medical Services
  • ABA Therapy
  • Residential Treatment
  • Intensive Outpatient Treatment
  • Partial Hospital /Day Treatment
  • Skilled Nursing Facility
  • Cognitive Rehabilitation
  • Occupational Therapy
  • Home Health Services
  • Inpatient Rehabilitation
  • Physical Therapy
  • Speech Therapy
  • Enteral Feeds
  • Long Term Acute Care Hospital (LTACH)
  • Intensity-Modulated Radiation Therapy (IMRT)
  • In Patient Admissions
Durable Medical Equipment
  • Spinal Cord Stimulators (implantation and device)
  • Continuous Glucose Monitoring Devices
  • Defibrillator Vests
  • Power Mobility Devices
  • Wound Vac
Medical Procedures
  • Septoplasty
  • UPPP, (Uvulopalatopharyngoplasty)
  • Varicose Vein Treatment
  • Blepharoplasty and/or Brow Lift
  • Gynecomastia Reduction
  • Mammoplasty
  • Panniculectomy
  • Rhinoplasty
  • Scar Revision outside doctor's office
  • Gastric Pacemaker
  • Bariatric Surgery, revisions, reversals (takedown) that require surgical intervention (eff. 1/1/12)
Radiology
  • Computerized Tomography (CT Scan)
  • Computerized Tomography - Angiography (CTA Scan)
  • Magnetic Resonance Imaging (MRI)
  • Magnetic Resonance Angiography (MRA)
  • Positron Emission Tomography (PET Scan)

You may view the ARBenefits Summary Plan Description at arbenefits.org for a full list of covered services and exclusions as well as pre-certification requirements.

Pharmacy prior authorization:

Please contact EBRx at 1-866 -564-8258 (Monday — Friday from 8 a.m. — 6 p.m. CST) to request approval for a prescription drug that requires a prior authorization. Exceptions for dosages in excess of the plan’s quantity limits, step therapy, and drugs not covered by the plan can be requested by calling Pharmacy Services at 855-757-9526 (Monday — Friday from 8 am — 4:30 pm CST).