Prior Authorizations

For all services requiring prior authorization, Providers must send requests to the UM Department via fax to (202) 721-7190 or via email at UM@hschealth.org. All non-urgent requests will be responded to within 14 calendar days. For issues requiring urgent attention, contact the UM Department at (202) 721-7162 to submit your request. All urgent requests will be responded to within 72 hours.

Note: Emergency and Stabilization Services (ER Services) never require a prior authorization request regardless of the network status of practitioner, providers or facility providing ER Services.

Out of Network services always require prior authorization. If a provider elects to refer an HSCSN enrollee to non-participating (out-of-network) specialist for any reason, this request must receive prior authorization from HSCSN before the HSCSN enrollee accesses the services.

The following services require notification:

Inpatient admission within 24 hours of admission or the next business day

Newborn Deliveries within 24 hours of delivery or the next business day

DME/DMS Delivery notification within 24 hours of delivery or the next business day

The following services DO NOT REQUIRE prior authorization when performed by an in-network provider:

• Primary Care Office Visits
• Specialty Office Visits
• Women Well Care Visits (including Depo-Provera shots)
• Vision Services (the first pair of standard eyeglasses do not require prior authorization)
• Labs and Radiology Services (including x-rays, sonograms, MRIs, CT and PET Scans)
• Outpatient Mental Health Services (psychiatric evaluations, substance abuse, medication management, and therapy services [individual, group, family]

The following services DO REQUIRE prior authorization when performed by an in-network provider:

• Applied Behavior Analysis (ABA) therapy
• Outpatient Rehabilitative Therapies:
  • Speech-Language Therapy
  • Physical Therapy
  • Occupational Therapy
  • Other: Acupuncture, Massage Therapy, Chiropractic Treatment, etc.
  • Skilled Nursing Visits
  • Private-Duty Nursing (shifts of nursing care)
  • Personal Care Aide Services / Home Health Aides
  • PT, OT, ST
  • Rehabilitation facilities
  • Skilled Nursing Facilities (SNF)
  • Psychiatric Residential Treatment Facilities (PRTF)
  • Intermediate Care Facilities for Intellectually and Developmentally Disabled (ICF-IDD)

  Pharmacy Provider Services Information

  Prior Authorization

  Providers can fax the Pharmacy Prior Authorization form to CVS Health at 1-888-836-0730 or call the CVS Utilization Management Department at (877) 433-7643.

  CVS Caremark Mail Order Service

  We encourage enrollees to use the CVS Caremark Mail Order Pharmacy. Below you will find the CVS Caremark Mail Order Fax Form. For additional information on Mail Order Services please contact CVS Health at (800) 875-0867. Forms can be faxed to: (800) 378-0323.

  Specialty Medications