Prior Authorization Rules for Medical Benefits
There are times when you will need to get approval before you can have a service done. This is called prior authorization. It is the job of the provider to get the approval from MHS Health.
Listed below are some of the services that need to be approved before you can get them.
Prior Authorization
Special Visits
- Plastic and reconstructive surgery
- Visits in the home setting
- Outpatient Therapy/Rehabilitation Services
- Speech therapy
- Occupational therapy
- Physical therapy
Surgical or Other Procedures
- Bariatric surgery (weight loss)
- Implantable devices including cochlear implant
- Mammoplasty (breast augmentation surgery)
- Rhinoplasty or septoplasty (nose plastic surgery)
- Treatment of varicose veins
Radiology Services
- Cardiac imaging including stress echocardiogram
Other Services and Tests
- Durable medical equipment (DME)
- Home health including personal care services
- Skilled nursing
- Hospice
- Quantitative drug testing
- Genetic testing
- Certain medications
Non-Participating/Out-of-Network Providers
In most cases you must see an MHS Health specialist or provider. If the service is available from MHS Health providers, we will ask that you use an MHS Health provider. If the service is not available from MHS Health providers, MHS Health may approve an out-of-network provider. We only approve out-of-state appointments when the service is not available in Wisconsin.
Referrals
Your provider may want to refer you to a specialist. MHS Health needs to approve many of those referrals. We want to make sure the service is needed and that provider is in our network.
There are many services that do not need a referral or approval.
- Emergency room care
- Routine women’s annual exams and preventative women’s health care services. These include but are not limited to prenatal care, breast exams, mammograms and Pap tests
- Pregnancy care
- Kidney dialysis services
- Immunizations (shots)