Authorizations/Precertifications

GEHA, like other federal health plans, requires providers to obtain authorization before some services and procedures are performed. You'll find more information on authorizations in the GEHA plan brochure. For quick reference, see the GEHA member's ID card.

The sources of our clinical guidelines can be found on our Sources of Clinical Guidelines summary (PDF).

If Medicare A or B pays primary benefits for these services, you do not need to obtain authorization.

If you are a member and you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the doctor or the hospital must call GEHA within two business days following the day of the emergency admission, even if you have been discharged from the hospital.

Although your physician or hospital will precertify your stay, it is your responsibility to ensure that precertification is complete. Failure to precertify inpatient stays could result in a benefits reduction. It is not necessary to precertify hospital admissions outside the United States. For more details on your GEHA coverage when traveling, click on Outside the United States.

To check benefits and eligibility, call GEHA's Customer Service department at 800.821.6136.

Surgeries/Procedures Requiring Authorization
Back – Spinal fusions/Multi-level spinal surgeries/Artificial disc replacements Authorization from OrthoNet is required. Providers should download a Spinal Surgery Authorization form, complete it and fax it (along with supporting documents) to OrthoNet at 877.304.4409. For assistance, call GEHA at 800.821.6136, Ext. 3100. At prompt, select option 7.

Please note: Charges billed by a facility for implantable devices, surgical hardware, etc., are subject to the Plan allowance, which is based on the provider’s cost plus 20% with submitted invoice, or two times the Medicare allowance without an invoice. Providers are encouraged to notify us on admission to determine benefits payable.

Breast Reconstruction
except for immediate reconstruction for DX: Cancer
Authorization is required. Providers should fax medical records (including CPT codes) to 816.257.3255. For assistance, call GEHA at 800.821.6136, Ext. 3100. At prompt, select option 4.
Coma Stimulation Authorization is required. Providers should fax medical records (including CPT codes) to 816.257.3255. For assistance, call GEHA at 800.821.6136, Ext. 3100.

Cosmetic Procedures

  • Blepharoplasty or other types of eyelid surgeries, browlift
  • Liposuction and scar revisions
  • Gynecomastia
Authorization is required.
  • For blepharoplasty or other types of eyelid surgeries, providers should download a Blepharoplasty Authorization form, complete it and fax it (along with supporting documents) to 816.257.3255. Do not fax images. For assistance with images, call GEHA at 800.821.6136, Ext. 3100. At prompt, select Option 4.
Diastasis Recti Repair Authorization is required. Providers should mail relevant medical records (including tried and failed treatments, photos and CPT codes) to GEHA at PO Box 4665, Independence, MO 64051-4665. For assistance, call GEHA at 800.821.6136, Ext. 3100.
Experimental/Investigation surgery or treatment Authorization is required. Providers should fax medical records (including CPT codes) to 816.257.3255. For assistance, call GEHA at 800.821.6136, Ext. 3100. At prompt, select Option 4.
Gender Dysphoria Authorization is required. Providers should download a Gender Dysphoria Authorization form, complete it and fax it to 816.257.3255. For assistance, call GEHA at 800.821.6136, Ext. 3100. At prompt, select Option 4.
Knee – Autologous Cultured Chondrocytes (ACI), also called Genzyme Tissue Repair Authorization is required. Providers should fax medical records (including CPT codes) to 816.257.3255. For assistance, call GEHA at 800.821.6136, Ext. 3100.
Mammoplasty: Reduction (unilateral/bilateral) Authorization is required. Providers should download a Breast Reduction Authorization form, complete it and fax it [along with supporting document(s) – including number of grams per breast to be removed] to 816.257.3255. Do not fax images. For assistance with images, call GEHA at 800.821.6136, Ext 3100. At prompt, select Option 4.
Mastectomy performed prophylactically Authorization is required. Providers should fax medical records (including CPT codes) to 816.257.3255. For assistance, call 800.821.6136, Ext. 3100. At prompt, select Option 4.
Morbid Obesity Surgeries

Authorization is required. Providers should download a Bariatric Authorization form, complete and fax to 816.257.3255. For assistance, call 800.821.6136, Ext. 3100. At prompt, select Option 4.

Orthognathic Surgery
(jaw) including TMJ
Authorization is required. Providers should mail authorization requests to GEHA FEHB Medical, P.O. Box 4665, Independence, MO 64051-4665. Authorization is not required for oral appliance, E0486.
Panniculectomy/Abdominoplasty Authorization is required. Providers should download a Panniculectomy/Abdominoplasty Authorization form, complete it and fax it [along with supporting document(s)] to 816.257.3255. Do not fax images. For assistance with images, call GEHA at 800.821.6136, Ext 3100. At prompt, select Option 4.
Rhinoplasty Authorization is required. Providers should download a Nasal Surgeries Authorization form, complete it and fax it [along with supporting document(s)] to 816.257.3255. Do not fax images. For assistance with images, call GEHA at 800.821.6136, Ext 3100. At prompt, select Option 4.
Septoplasty Septoplasty alone does not require authorization. If billing with additional procedure(s), providers should download a Nasal Surgeries Authorization form, complete it and fax it [along with supporting document(s)] to 816.257.3255. Do not fax images. For assistance with images, call GEHA at 800.821.6136, Ext 3100. At prompt, select Option 4.
Sleep Study Program (In Lab)
In-lab/outpatient/attended sleep study services for patients ages 19 or older that include:
  • 95805
  • 95807
  • 95808
  • 95810
  • 95811
Authorization is required.
  • For In-Lab Sleep Study services, download an In-Lab Sleep Study Authorization form, complete the form and fax it (along with requested documents) to 816.257.4516. Be sure to check one of the appropriate listed conditions and provide supporting documentation. Do not fax images. For help with images, please contact GEHA's Call Center at 800.821.6136.

Please note: Home sleep studies do not require authorization. Please only submit authorization requests for the procedures listed on the left.

Sympathectomy by Thoracoscopy or Laparoscopy Authorization is required. Providers should fax medical records (including tried and failed treatments and CPT codes) to 816.257.3255. For assistance, call 800.821.6136, Ext. 3100. At prompt, select Option 4.
Uvulopalatopharyngoplasty (UPP) Authorization is required. Providers should fax medical records (including tried and failed treatments and CPT codes) to 816.257.3255. For assistance, call 800.821.6136, Ext. 3100. At prompt, select Option 4.
Vein Surgeries (leg) The following require authorization:
  • Ablation therapy
  • Stab phlebectomy
  • Other vein procedures
Providers should download a Vein Surgeries Authorization form, complete it and fax it (along with supporting documents) to 816.257.3255. For assistance, call GEHA at 800.821.6136, Ext. 3100. At prompt, select option 4.

Sclerosing therapy is not a covered benefit.
Services Requiring Authorization
Applied Behavior Analysis (ABA) Therapy



Speech-Generating Devices for ASD
Authorization from Health Integrated is required. Providers should download an Applied Behavior Analysis Service request form, complete it and fax it (along with supporting documents) to Health Integrated at 888.974.5948. For help, call Health Integrated at 888.211.6922. To obtain a form via fax, call GEHA at 800.821.6136, Ext 3100. At prompt, select option 5.


Authorization from Health Integrated is required for members ages 12 months to 17 years old. Providers should download an Assistive Communication Device request form, complete it and fax it (along with supporting documents) to Health Integrated at 888.974.5948. For members 18 years or older, download a Durable Medical Equipment (DME) Authorization form, complete it and fax it to 816.257.3515 or 816.257.3255. For assistance, call Health Integrated at 888.211.6922. To obtain a form via fax call GEHA at 800.821.6136, Ext. 3100. At prompt, select option 5.
Cancer Treatment – non-surgical All non-surgical outpatient cancer treatments require preauthorization. To obtain preauthorization, providers should log in to eviti.com and select the appropriate cancer treatment.

If you choose an evidence-based treatment, you will receive immediate authorization approval, called an eviti code. If you wish to submit a customized treatment plan, you may do so. However, customized plans require special review and may delay your authorization. If you experience any issues using the eviti.com site, please contact eviti support at 888.678.0990.

Please note: Based on the GEHA member's benefits, some medications must be obtained from CVS Caremark to avoid penalties to the member. For information about which drugs require specialty dispensing, please contact CVS Caremark at 855.240.0536.

For other questions, please call Customer Service, Ext. 3100. At prompt, select option 1.
Dialysis Services Authorization is required for end-stage renal disease outpatient dialysis services. Providers should download a Dialysis Authorization form, complete it and fax it (along with supporting documents) to 816.257.3255. For assistance, call 800.821.6136, Ext. 3100. At prompt, select option 1. If the patient is an inpatient, please see Hospital – Medical/Surgical Inpatient Care.
Durable Medical Equipment Authorization is sometimes required. Providers should download a Durable Medical Equipment (DME) Authorization form, complete it and fax it (along with supporting documents) to 816.257.3515 or 816.257.3255. For assistance, call 800.821.6136, Ext. 3100. At prompt, select option 3.

For cranial helmets, color pictures must be mailed to GEHA Care Management at PO Box 4665, Independence, MO 64051-4665.

These supplies and equipment do not require authorization:
  • Walkers: E0130-E0149
  • Platform attachment for walkers: E0153-E0159
  • Canes: E0100-E0105
  • Crutches: E0110-E0118
  • Compression stockings: A6530-A6549
  • Ostomy supplies: A4361-A4415
  • External urinary catheters: A4356-A4358
  • Incontinence catheters: A4310-A4335
Genetic Testing Online authorization from evicore.com is required. Before starting the online authorization process, providers should download the Quick Reference Guide to Genetic Testing (PDF). For assistance, call 866.879.8317.
Hospital – Medical/Surgical Inpatient Care

Mental Health – Inpatient 
Care for Mental Health/Substance Abuse, including Residential and Intensive Day Treatment
Authorization for acute inpatient care requires an authorization from Conifer Health Solutions. Providers/hospitals* should call Conifer Health Solutions at 800.242.1025; Fax: 866.315.6314. Please note that if the procedure or surgery requires authorization, it will be necessary to obtain approval for the procedure before having the hospital stay authorized. Please contact Customer Service for surgical procedure authorization at 800.821.6136.
Mental Health – Outpatient
Psychological Testing, Neuropsychological Testing
Authorization is required for psychological or neuropsychological testing only if more than 6 hours of testing will be done. Providers should download a Psychological or Neuropsychological Testing Authorization form, complete it and fax it to 816.257.3515 or 816.257.3255. For assistance, call GEHA at 800.821.6136, Ext. 3100. At prompt, select option 1.
Mental Health – Outpatient
Electroconvulsive Therapy (ECT), Transcranial Magnetic Stimulation (TMS), Vagus Nerve Stimulation (VNS)
Authorization is required. Providers should download a TMS/ECT Authorization form, complete it and fax it to 816.257.3515 or 816.257.3255. For assistance, call GEHA at 800.821.6136, Ext. 3100. At prompt, select option 1.
Orthotics and Prosthetics Authorization is required for some orthotics and prosthetics.

Orthotics: Call GEHA at 800.821.6136, Ext. 3100. At prompt, select option 3.

Prosthetics: Providers should download a Prosthetic Device Authorization form, complete and fax it (along with supporting documents) to 816.257.3515 or 816.257.3255. For assistance, call 800.821.6136, Ext. 3100. At prompt, select option 3.

Authorization is not required for mastectomy bras and prosthetics (L8000-L8039) with a diagnosis of breast cancer, or post mastectomy or lumpectomy.
Pain Management
Epidural injections, FACET injections, Intrathecal pump insertion for pain (morphine, baclofen, etc.), spinal cord stimulators
Authorization from OrthoNet is required. Providers should download a Pain Management Authorization form, complete it and fax it (along with supporting documents) to OrthoNet at 888.539.3049. For assistance, call GEHA at 800.821.6136, Ext. 3100. At prompt, select option 7.
Prescription Drugs Some medications must be approved by GEHA and or CVS Caremark before they are a covered benefit. Members must make sure that their physicians obtain the prior approval/authorization for certain prescription drugs and supplies before coverage applies. Medication may be limited as to its quantity, total doses, duration of therapy, age, gender or specific diagnosis. Pre-approval/authorizations must be renewed periodically. See Prescription Drug Benefits in the GEHA Plan Brochure. To obtain these medications, contact CVS Caremark at 855.240.0536.
Specialty Prescription Drugs Specialty Drugs are used to treat some severe medical conditions and are usually administered by injection or infusion. See Specialty Drug Benefits in the GEHA Plan Brochure. To obtain these medications, contact CVS Caremark at 855.240.0536.
Radiology
  • CT (computerized axial tomography)
  • MRA (magnetic resonance angiography)
  • MRI (magnetic resonance imaging)
  • NC (nuclear cardiac imaging studies)
  • PET (positron emission tomography).
Authorization from eviCore healthcare (formerly MedSolutions) is required. Ask your provider to call 866.879.8317 or visit evicore.com before scheduling the procedure.

About US Imaging: After you obtain eviCore healthcare's (formerly MedSolutions) authorization, you might be contacted by US Imaging, which is an optional scheduling program for GEHA members. However, you always have the option of going to the facility of your choice. You can contact US Imaging by phone at 877.904.3877 or online at usimagingnetwork.com

US Imaging does not schedule services for members with Medicare A& B primary or Medicare Part B only. US Imaging does not schedule services in states where GEHA contracts with the Coventry and Freedom provider networks.

Services that are not preauthorized will require retrospective review for medical necessity. If the service is approved, it is subject to a $100 penalty.
Skilled Nursing: Inpatient
Includes Skilled Nursing, Long-Term Acute Care and Inpatient Rehabilitation facilities
Authorization from OrthoNet is required. Providers should call OrthoNet at 877.304.4419; Fax: 877-304-4409. For assistance, call 800.821.6136, Ext. 3100. At prompt, select option 5.
Skilled Nursing: Outpatient
Includes Home Skilled Nursing Care, IV Therapy
Authorization is required. Please call GEHA at 800.821.6136, Ext. 3100. At prompt, select option 2.
Therapy Services: Physical, Occupational and Speech Authorization from OrthoNet is required. Providers should call OrthoNet at 877.304.4399; Fax: 877-304-4409. For assistance, call 800.821.6136, Ext. 3100. At prompt, select option 5.
Therapy Services: Cardiac Rehabilitation Authorization is required for services after 36 visits. Providers should fax physician progress notes and separate rehab notes with 
medical records (including cardiac history and recent cardiac events or procedures) to 816.257.3255. For assistance, call 800.821.6136, Ext. 3100. At prompt, select option 4.
Therapy Services: Pulmonary Rehabilitation Authorization is required for services after 24 visits. Providers should fax physician progress notes and separate rehab notes with 
medical records (including medications, pulmonary function tests and O2 levels) to 816.257.3255. For assistance, call Customer Service at 800.821.6136, Ext. 3100. At prompt, select option 4.
Total Parenteral Nutrition Authorization is required. Providers should download a TPN (Total Parenteral Nutrition) Authorization form, complete and fax it (along with supporting documents) to 800.821.6136 or 816.257.3255. For assistance, call 800.821.6136, Ext. 3100. At prompt, select option 2.
Transplants
 (other than cornea or kidney)
Authorization is required most transplants. For authorization and help identifying facilities within GEHA's transplant network, call 800.821.6136, Ext. 3100. Authorization is not required for cornea or kidney transplants, which are paid under GEHA's medical benefit.
Wound Care Services: Outpatient
Includes HBO, wound vac, skin grafting and skilled-nursing services associated with the wound care
Authorization is required. Providers should download a Wound Care Authorization form, complete and fax it (along with supporting documents, including tried and failed treatment, history, wound measurements and treatment plan) to 816.257.3255. For assistance, call 800.821.6136, Ext. 3100. At prompt, select option 2.