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10421 South Jordan Gateway, Suite 400 South Jordan, Utah 84095 Prior Authorization Telephone #: 1-801-323-6440 or 1-800-879-0234 Prior Authorization Fax #: 1-801-323-6160 or 1-800-434-6250 Customer Service Number: 1-801-323-6200 or 1-800-377-4161

Prior Authorization Requirements

I.

SERVICES WHICH REQUIRE PRIOR AUTHORIZATION FOR ALL ALTIUS MEMBERS REGARDLESS OF PLAN: A. ALL INPATIENT ADMISSIONS/PROCEDURES REQUIRE AUTHORIZATION/NOTIFICATION · ELECTIVE INPATIENT ADMISSIONS · OBSTETRICAL CARE, DELIVERY AND C-SECTION (requires notification). · REHABILITATION · SNF B. BEHAVIORAL HEALTH SERVICES (Contact MHNet at 1-800-782-2052 for prior authorization) ­ Includes, but is not limited to, evaluation and service, substance abuse detoxification programs/services. C. COSMETIC PROCEDURES - potentially cosmetic procedures include, but are not limited to, tattoos, collagen injections, rhinoplasty, scar revision, keloid care, otoplasty, surgical repair of gynecomastia, pectus deformity, mammoplasty, abdominoplasty, venous injection, ligation, or ablation, use of tissue expanders, dermabrasion, Lesion removals, (frenotomy 40806, 41010). D. DURABLE MEDICAL EQUIPMENT ­ · Praxair Medical - to order DME contact Praxair Medical at any of their branches. For items not available at Praxair, or supplied by other contracted providers, such as bone healing devices, orthopedic braces, and insulin pumps, please contact Altius Health Plans customer service or prior authorization. · Lincare (Wyoming) ­ to order DME contact Lincare at any of their branches. For items not available at Lincare, or supplied by other contracted providers, such as bone healing devices, orthopedic braces, and insulin pumps, please contact Altius Health Plans customer service or prior authorization. · HEARING ENHANCEMENT ­ includes devices and procedures to promote hearing E. HOME HEALTH CARE INCLUDING HOME INFUSION THERAPY F. DENTAL AND DENTAL RELATED SERVICES ­ includes, but is not limited to, periodontal procedures, gingivectomy, gingivoplasty, operculectomy, alveolectomy, excision of tuberosities, interdental fixation, general anesthesia for dental procedures.

G. MEDICATIONS ­ injectables, implantable medications and devices, and selected oral and topical medications (refer to preferred drug list or the Altius Health Plans web site www.altiushealthplans.com) H. OTHER SERVICES/PROCEDURES WHICH REQUIRE AUTHORIZATION · · · · · · · ABORTION SERVICES - elective abortion and multi-fetal pregnancy reduction BRACHYTHERAPY CAPSULE ENDOSCOPY CARDIAC NUCLEAR MEDICINE SCANS CHIROPRACTIC TREATMENT ­ Utah members contact CHP at 1-800-339-5958 CIRCUMCISION (over 3 months of age) COMPUTED TOMOGRAPHY (CT) ANGIOGRAMS

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CPAP titration studies - not performed on the same night as a diagnostic sleep study EXAMINATIONS PERFORMED UNDER GENERAL ANESTHESIA EYEGLASSES AND CONTACT LENSES ­ after cataract surgery, or for other covered conditions as specified in members benefit brochure GASTRIC RESTRICTIVE PROCEDURES GENETIC COUNSELING ­ notification only for first two visits, then requires authorization GENETIC TESTING ­ evaluation and treatment, cytogenetic testing, molecular diagnostic testing GRAFTS - including nerve, bone, cartilage, tendon, muscle, tissue HEALTH EDUCATION HOSPICE SERVICES ­ Inpatient and Outpatient HYPERBARIC THERAPY INFERTILITY TREATMENT ­ includes, but is not limited to, artificial insemination, in-vitro fertilization, fimbrioplasty, tuboplasty, wedge resection of the ovary, GIFT, ZIFT, repair of epididymis, vasotomy, varicocele repair, penile prosthesis INTIMA MEDIA THICKNESS TESTING (IMT) JOINT REPLACEMENT (EXCEPT HIP AND KNEE) MAGNETOENCEPHALOGRAPHY (MEG) MAMMOPLASTY, MASTOPEXY, MASTECTOMY, BREAST RECONSTRUCTION MANDIBULAR PROCEDURES - including condylectomy, meniscectomy, orthognathic surgery, TMJ Arthroplasty MEDICAL NUTRITION THERAPY NEUROPSYCHIATRIC TESTING OCULOPLASTIC PROCEDURES - including blepharoplasty, brow ptosis, ectropion, Entropion OPTHALMOLOGICAL SURGERY - including radial keratotomy, LASIK, keratomileusis, keratophakia, corneal relaxing incisions, corneal wedge resection ORAL PROCEDURES - including uvular lingula and palatal procedures such as UPPP, removal of osseous tuberosities, TONGUE RESECTION ORTHOTICS, PROSTHETICS, AND CORRECTIVE APPLIANCES OUTPATIENT THERAPY ­ Occupational, Physical, Speech, and other outpatient rehabilitative services PAIN MANAGEMENT ­ Services which require authorization include: nerve blocks, epidural injections, neurotomy, chemical neurolysis, facet joint injections, implantation of drug infusion pump, implantation of neurostimulator. Office visits for the evaluation and follow-up care for medication management will not require authorization. PET and PET Fusion Scan PLASTIC SURGERY AND RELATED PROCEDURES SALIVARY GLAND PROCEDURES SPINAL SURGERY SYMPATHECTOMY THREE-DIMENSIONAL IMAGING TRANSPLANTS ­ Including initial evaluation and donor testing TRANSPORTATION - all non-urgent forms of transportation UMBILICAL HERNIA REPAIR ­ members less than one year old VEIN SURGERIES ALL PROCEDURES CODED AS UNLISTED PROCEDURES

NOTIFICATION ONLY PROCEDURES (Requires notification to Altius but no clinical information): · Amputation · Arthroplasty ­ Hip, Knee · Cardiac Valve Replacement or valvotomy · Cerebrospinal fluid shunt · Cleft lip/palate repair

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Colectomy Coronary Artery Bypass Surgery Craniotomy Major uterine surgery including hysterectomy, uterine suspension, enterocele/rectocele repair Laryngectomy Mastectomy for malignancy and reconstruction breast(s) Nephrectomy Oophorectomy Orchiectomy Pneumonectomy Prostatectomy Repair of Aortic Aneurysm Repair of Cerebral Aneurysm Whipple Procedure

ALL NON-EMERGENT/NON-URGENT SERVICES FROM NON-CONTRACTED PROVIDERS REQUIRE PRIOR AUTHORIZATION UNLESS THE MEMBER HAS A POINT OF SERVICE (POS) PLAN, THEN REGULAR AUTHORIZATION RULES APPLY.

IIII.

PROCEDURES ADDED TO THIS LIST ON 7-1-07 · · · · · · · · · · · · · · · · · · · · · Brachytherapy Cardiac nuclear medicine scans Computed Tomography (CT) angiograms Intima media thickness testing (IMT) Arthrodesis, Arthroplasty, or Arthrotomy of the upper extremities, foot and ankles Salivary gland procedures Three-dimensional imaging

V.

LANGUAGE REMOVED FROM THIS LIST ON 4/07 IN ADDITION TO THE OUTPATIENT PROCEDURES LISTED ABOVE, ALL OUTPATIENT SURGERIES OUTSIDE OF THE STATE OF UTAH REQUIRE PRIOR AUTHORIZATION, UNLESS THE MEMBER HAS A PEAK EXTENDED PLAN, THEN REGULAR AUTHORIZATION RULES APPLY

VI.

PROCEDURES REMOVED FROM THIS LIST ON 5-21-08 · · · ARTHRODESIS, ARTHROPLASTY, OR ARTHOTOMY ­ Of the upper extremities, foot, and ankle

PRIOR AUTHORIZATION DOES NOT GUARANTEE PAYMENT. ELIGIBILITY AND BENEFITS MUST BE VERIFIED WITH ALTIUS HEALTH PLANS CUSTOMER SERVICE DEPARTMENT AND WILL BE DETERMINED AT THE TIME THE CLAIM IS SUBMITTED.

Revised Nov 2008

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ALTIUS HEALTH PLANS

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