Prior Authorizations
For some types of care, PHP (HMO SNP) providers will need to ask for pre-approval or prior authorization before providing care. This allows PHP to make sure the care is medically necessary.
The following services always need pre-approval (prior authorization), even if they are given from a provider in the PHP network:
- Hospitalization, if not an emergency
- Services out of the PHP service area, if not an emergency or urgent care
- Outpatient surgery
- Long-term care or skilled nursing services at a nursing facility
- Specialized treatments, imaging, testing, and procedures
- Medical transportation services when it is not an emergency
Prior Authorization requests must be made using the Prior Authorization Request Form. For additional information on prior authorizations or general plan information please consult the current PHP Provider Manual.
Additional Information on Prior Authorizations
For a more complete description of these covered services that may require prior authorization, please see Chapter 4, Section 2 of the 2026 Evidence of Coverage.
- Acupuncture for chronic low back pain
- Chemotherapy, photo and radiation therapy
- Durable medical equipment (DME) and related supplies
- EMG, nerve conduction studies
- Hearing services (prior authorization required for hearing aids)
- Home and bathroom safety devices and modifications
- Home health agency care
- Home infusion therapy
- In-Home Support Services
- Inpatient hospital care
- Inpatient services in a psychiatric hospital
- Inpatient stay: Covered services received in a hospital or SNF during a non-covered inpatient stay (some services require prior authorization)
- Interventional radiology & nuclear medicine
- Massage Therapy
- Meal benefit
- Medical nutrition therapy (This is a Medicare preventative service)
- Medicare Part B prescription drugs (certain drugs require prior authorization)
- Out-of-network services
- Outpatient hospital services (some services require prior authorization)
- Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers
- Part B Drugs (Physician Office Administered), excluding immunizations
- Partial hospitalization services and intensive outpatient services
- PET scans
- Physician/Practitioner services, including doctor’s office visits (some services require prior authorization)
- Podiatry services (certain services require prior authorization)
- Prosthetic and orthotic devices and related supplies
- Pulmonary rehabilitation services (certain services require prior authorization)
- Services to treat kidney disease (requires prior authorization except when out of the services area)
- Skilled nursing facility (SNF) care
- Special Supplemental Benefits for the Chronically Ill (SSBCI) (each SSBCI benefit requires prior authorization)
- Transportation
- Vision care (prior authorization required for certain Medicare-covered vision services)
- Wound Care
For a more complete description of these covered services that do not require prior authorization, please see Chapter 4, Section 2 of the 2026 Evidence of Coverage.
- *Most Original Medicare preventative services (Medical nutrition therapy requires authorization)
- Acupuncture
- Ambulance services
- Cardiac rehabilitation services
- Chiropractic services
- Chronic pain management and treatment services
- Emergency care (Emergency care is covered only within the United States)
- Hospice Care (non-emergency, non-urgently needed services covered under Medicare Part A or B that aren’t related to the terminal prognosis may be subject to prior authorization)
- Opioid treatment program services
- Outpatient diagnostic tests and therapeutic services and supplies
- Outpatient hospital observation
- Outpatient mental health care
- Outpatient rehabilitation services
- Outpatient substance use disorder services
- Over-the-counter (OTC) pharmacy Items
- Supervised Exercise Therapy (SET)
- Urgently needed services (Urgent care is covered only within the United States)
A standard coverage decision is usually made within 7 calendar days when the medical item or service is subject to our prior authorization rules, 14 calendar days for all other medical items and services, or 72 hours for Part B drugs. A fast (expedited) coverage decision is generally made within 72 hours, for medical services, or 24 hours for Part B drugs.
For more information about fast (expedited) coverage decisions and the requirements to get one please see Chapter 9, Section 5 of the 2026 Evidence of Coverage.
For transparency with our enrollees and providers, as well as alignment with the CMS Interoperability and Prior Authorization final rule, PHP publishes an annual report of our prior authorization metrics for the prior year. This report covers the prior authorization data for medical services (excluding prescription drugs).
For certain drugs, you or your provider need to get approval (prior authorization) from our plan based on specific criteria before we agree to cover the drug for you. This is put in place to ensure medication safety and help guide appropriate use of certain drugs. If you don’t get this approval, your drug might not be covered by our plan. You can view the 2026 Prescription Drug Prior Authorization Criteria if you would like to review a specific drug.
For more information about coverage decisions or appeals of Part D drugs please see Chapter 9, Section 6 of the 2026 Evidence of Coverage.
For additional information or if there are any questions on prior authorizations, please contact the Utilization and Case Management Department at (800) 474-1434, Monday through Friday, 8:30 a.m. to 5:30 p.m. (TTY 711).
