Authorizations/Precertifications for Elevate and Elevate Plus Members

 

Note: The authorization information on this page is for GEHA's Elevate and Elevate Plus plan members. For our other medical plans, visit Authorizations/Precertifications for HDHP, Standard and High Option members.

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 or another group health insurance policy is the primary payer 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 Care department at 800.821.6136.



Surgeries/Procedures Requiring Authorization
Back – Spinal fusions/Multi-level spinal surgeries/Artificial disc replacements Authorization from UnitedHealthcare is required. Providers should call UnitedHealthcare at 866.257.0721.

Please note: Charges billed by an out-of-network 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 Procedures

Breast Reconstruction (except for immediate reconstruction for DX: Cancer)
Authorization is required. Providers should call UnitedHealthcare at 866.257.0721.

Gynecomastia: Reduction (unilateral/bilateral)
For other cosmetic procedures, providers should call UnitedHealthcare at 866.257.0721.

Mammoplasty: Reduction (unilateral/bilateral)
Authorization is required. Providers should call UnitedHealthcare at 866.257.0721.

Mastectomy performed prophylactically
Authorization is required.Providers should call UnitedHealthcare at 866.257.0721.


Reconstructive Surgery

  • Blepharoplasty or other types of eyelid surgeries, browlift
  • Liposuction and scar revisions
Authorization is required.

For blepharoplasty or other types of eyelid surgeries, providers should call UnitedHealthcare at 866.257.0721.

Unlisted CPT codes, T-Codes, and procedures that are listed as experimental and investigational according to UnitedHealthcare clinical coverage policies and/or could be considered experimental and investigational. Authorization is required. Providers should call UnitedHealthcare at 866.257.0721.


Gender Reassignment Surgery Authorization is required. Providers should call UnitedHealthcare at 866.257.0721.


Osteochondral grafting of articular lesions including autologous chondrocyte transplants Authorization is required. Providers should call UnitedHealthcare at 866.257.0721.


Bariatric Surgeries
(Weight-loss surgery)

Authorization is required. Providers should call UnitedHealthcare at 866.257.0721.


Orthognathic Surgery
Orthognathic surgery for the following conditions:
  • severe sleep apnea only after conservative treatment of sleep apnea has failed
  • cleft palate and Pierre Robin Syndrome
Authorization is required. Providers should call UnitedHealthcare at 866.257.0721.


Panniculectomy/Abdominoplasty/Lipectomy Authorization is required. Providers should call UnitedHealthcare at 866.257.0721.


Rhinoplasty Authorization is required. Providers should call UnitedHealthcare at 866.257.0721.
  • Septoturbinoplasty does not require authorization when performed alone.
  • Septoturbinoplasty does require review when combined with either a rhinoplasty or a sinus surgery.
Sinus surgery Authorization is required. Providers should call UnitedHealthcare at 866.257.0721.
  • Septoturbinoplasty does not require authorization when performed alone.
  • Septoturbinoplasty does require review when combined with either a rhinoplasty or a sinus surgery.
Sleep Study Program (In Lab)
In-lab/outpatient/attended sleep study services
Authorization is required. Providers should call UnitedHealthcare at 866.257.0721.

Please note: Home sleep studies do not require authorization.

Uvulopalatopharyngoplasty (UPP) Authorization is required. Providers should call UnitedHealthcare at 866.257.0721 to obtain authorization.
Vein Surgeries (leg) Authorization is required. Providers should call UnitedHealthcare at 866.257.0721 to obtain authorization.
Services Requiring Authorization
Applied Behavior Analysis (ABA) Therapy Authorization for ABA services from Optum is required. Providers should contact Optum at 855.583.3164 for authorization.

Optum does not accept fax request. Providers are required to complete an Applied Behavioral Analysis (ABA) assessment when requesting ABA services for the first time. The form does not need to be completed for members currently utilizing ABA services. This form gathers information needed to authorize the initial ABA assessment and is used to build the treatment plan. The form is updated during the concurrent review that generally takes place at 6 months. The ABA assessment must be approved before the ABA treatment starts. Once the assessment is complete, the provider can call and complete the clinical review over the phone.

Complete an online ABA assessment form – ABA Therapy requires prior authorization. Providers wanting to obtain prior authorization for ABA Therapy should call Optum at 855.583.3164 to complete an authorization live review.
Speech-Generating Devices Authorization is required. Providers should call UnitedHealthcare at 866.257.0721.
Cancer Treatment – non-surgical All non-surgical outpatient cancer treatments require preauthorization. To obtain preauthorization, providers should contact Optum Healthcare at 866.257.0721.

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.

Dialysis Services Authorization is required for end-stage renal disease outpatient dialysis services. Providers should call UnitedHealthcare at 866.257.0721.

Durable Medical Equipment Authorization is sometimes required. Providers should call UnitedHealthcare at 866.257.0721.

Genetic Testing Authorization for genetic testing is required. Providers should call UnitedHealthcare at 866.257.0721.
Hospital – Medical/Surgical Inpatient Care

Mental Health – Inpatient
Care for Mental Health/Substance Abuse, including Residential Treatment Centers.

Mental Health – Outpatient
Care for Mental Health/Substance Abuse, including Intensive Day Treatment, Partial Hospitalization Program, Intensive Outpatient Program.
Authorization for acute inpatient care required. Providers should call UnitedHealthcare at 866.257.0721.
Mental Health – Outpatient
Psychological Testing, Neuropsychological Testing
Authorization is required for psychological or neuropsychological testing. Providers should call UnitedHealthcare at 866.257.0721.
Mental Health – Outpatient
Electroconvulsive Therapy (ECT), Transcranial Magnetic Stimulation (TMS).
Authorization is required. Providers should call UnitedHealthcare at 866.257.0721.
Orthotics and Prosthetics Authorization is required for some orthotics and prosthetics. Providers should call UnitedHealthcare at 866.257.0721.

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 is required for pain management. Providers should call UnitedHealthcare at 866.257.0721.
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 is required. Ask your provider to call 866.879.8317, prompt #1 to obtain authorization.

About GEHA SmartChoice: After you obtain eviCore Healthcare's authorization, you might be contacted by SmarthChoice, 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 SmartChoice by phone at 888.444.6184.
Skilled Nursing: Inpatient
Includes Skilled Nursing, Long-Term Acute Care and Inpatient Rehabilitation facilities
Elevate Plus plan members: Authorization is required. Providers should call UnitedHealthcare at 866.257.0721. Elevate plan members: Authorization is required for Long-Term Acute Care and Inpatient Rehabilitation facilities. Providers should call UnitedHealthcare at 866.257.0721. There is no benefit for Skilled Nursing facilities for Elevate Plan members.
Skilled Nursing: Outpatient
Includes Home Skilled Nursing Care, IV Therapy
Authorization is required. Providers should call UnitedHealthcare at 866.257.0721.

Cognitive Rehabilitation

Authorization is required. Providers should call UnitedHealthcare at 866.257.0721.

Therapy Services: Physical, Occupational and Speech

Physical Therapy, Speech Therapy and Occupational Therapy for physical rehab do not require authorization.  

Transplants
 (other than cornea)
Authorization is required for most transplants. Providers should call UnitedHealthcare at 866.257.0721. Authorization is not required for cornea transplants.
Wound Care Services: Outpatient
Includes wound vacuum devices and skin grafting.
Authorization is sometimes required. Providers should call UnitedHealthcare at 866.257.0721.