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Authorizations/Precertifications HDHP, Standard and High Option members
Note: The authorization information on this page is for GEHA's HDHP, Standard and High Option plan members. If the patient lives in Alabama, Arkansas, California, Delaware, Florida, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Louisiana, Maryland, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Mexico, North Carolina, North Dakota, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Virginia, Washington D.C., West Virginia, Wisconsin or Wyoming, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus at 877.585.9643. For our other medical plans, visit Authorizations/Precertifications for Elevate and Elevate Plus 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 Utilization Management Criteria (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.
Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission.
| Surgeries/Procedures Requiring Authorization | |
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| Arthroplasty Procedures — Hips, knees, shoulders, elbows | Authorization is required. Providers should download an Arthroplasty Authorization form, complete it and fax it (along with supporting documents) to 816.257.3515 or 816.257.3255. For help, call GEHA at 800.821.6136, ext. 3100. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Back — Spinal fusions/Multi-level spinal surgeries/Artificial disc replacements | Authorization is required. Providers should download a Spinal Surgery Authorization form, complete it and fax it (along with supporting documents) to 816.257.3515 or 816.257.3255. For help, call GEHA at 800.821.6136, ext. 3100.
Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. 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. |
| Bariatric Surgeries (Weight-loss surgery) |
Authorization is required. Providers should download a Bariatric Authorization form, complete and fax (along with supporting documents) to 816.257.3255. For help, call 800.821.6136, Ext. 3100.
Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Breast Procedures |
Breast Reconstruction
(except reconstruction for diagnosis of breast cancer) Authorization is required. Providers should download a Breast Reconstruction authorization form, complete it and fax it (along with supporting documents ) to 816.257.3255. For help, call GEHA at 800.821.6136, Ext. 3100. Gynecomastia: Reduction (unilateral/bilateral) For other cosmetic procedures, providers should download a Experimental/Investigational and Cosmetic Authorization form, complete it and fax it (along with supporting documents) to 816.257.3255. Do not fax images. Email images to caremanagementsurgery@geha.com. For further assistance with images, 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. Mastectomy performed prophylactically Authorization is required. Providers should fax medical records (including CPT codes) to 816.257.3255. For help, call 800.821.6136, Ext. 3100. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
Cardiovascular
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Authorization is required. Providers should download a Cardiovascular Authorization form, complete it and fax it (along with supporting documents) to 816.257.3515 or 816.257.3255. For help, call GEHA at 800.821.6136, ext. 3100. |
| Cartilage Implant | Authorization is required. Providers should download an Experimental/Investigational and Cosmetic Authorization form, complete it and fax it (along with supporting documents) to 816.257.3515 or 816.257.3255. For help, call GEHA at 800.821.6136, ext. 3100. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Cochlear Implants | Authorization is required. Providers should fax authorization requests (along with supporting documents) to 816.257.3515 or 816.257.3255. For help, call GEHA at 800.821.6136, ext. 3100. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Gender Affirmation Surgery | Authorization is required. Providers should download a Gender Affirmation Surgery Authorization form, complete it and fax it (along with supporting documents) to 816.257.3255. For help, call GEHA at 800.821.6136, ext. 3100. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Hysterectomy Surgery | Authorization is required. Providers should download a Hysterectomy Authorization form, complete it and fax it (along with supporting documents) to 816.257.3255. For help, call GEHA at 800.821.6136, ext. 3100. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Orthognathic Surgery Orthognathic surgery for the following conditions:
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Authorization is required. Providers should fax authorization requests (along with supporting documents) to 816.257.3515 or 816.257.3255. For help, call 800.821.6136, ext. 3100.
Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Osteochondral grafting of articular lesions including autologous chondrocyte transplants | Authorization is required. Providers should download a Osteochondral Authorization (including Grafting and Autologous Cultured Chondrocyte Implantation) form, complete it and fax it (along with supporting documents) to to 816.257.3255. For help, call GEHA at 800.821.6136, ext. 3100.
Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Panniculectomy/Abdominoplasty/Lipectomy | 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. Email images to caremanagementsurgery@geha.com. For further assistance with images, call GEHA at 800.821.6136, Ext 3100.
Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
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Reconstructive Surgery
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Authorization is required. For blepharoplasty or other types of eyelid surgeries, providers should download a Reconstructive Eyelid Surgery Authorization form, complete it and fax it (along with supporting documents) to 816.257.3255. Do not fax images. Email images to caremanagementsurgery@geha.com. For further assistance with images, call GEHA at 800.821.6136, Ext. 3100. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Rhinoplasty/Sinus surgery | Authorization is required. Providers should download and submit a Nasal Surgeries Authorization form (along with supporting documents).
Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission.
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| Sleep Study Program (In Lab) In-lab/outpatient/attended sleep study services for patients ages 18 or older that include:
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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. Email images to caremanagementsurgery@geha.com. For further 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. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Unlisted CPT codes, T-Codes, and procedures that are listed as experimental and investigational according to GEHA clinical coverage policies and/or could be considered experimental and investigational. | Authorization is required. Providers should fax medical records (including CPT codes and supporting documents) to 816.257.3255. For assistance, call GEHA at 800.821.6136, Ext. 3100.
Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Uvulopalatopharyngoplasty (UPP) | Authorization is required. Providers should download a Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome Authorization form, complete it and fax it (along with supporting documents and tried and failed treatments) to 816.257.3255. For assistance, call 800.821.6136, Ext. 3100. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Vein Surgeries (leg) | The following require authorization:
Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Services Requiring Authorization | |
|---|---|
| Applied Behavior Analysis (ABA) Therapy | Authorization is required. Providers should contact Optum at 855.583.3164 for authorization. Optum does not accept fax requests. 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. Follow this link to complete an online ABA assessment form. |
| Behavioral Health — Inpatient/Outpatient Care for Behavioral Health/Substance use Includes Residential Treatment centers, Partial Hospitalization Program and Intensive Outpatient Program |
Authorization is required. Providers should contact Optum Behavioral Health. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission.
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| Behavioral Health — Psychological and Neuropsychological Testing | Authorization is required for psychological and neuropsychological testing only if more than 8 hours of testing will be done. Providers should complete the online Optum authorization form.
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| Behavioral Health — ECT and TMS Electroconvulsive Therapy (ECT) Transcranial Magnetic Stimulation (TMS). |
Authorization is required. Providers should complete the online Optum authorization form. Authorization is required. Providers should contact Optum Behavioral Health. Refer to the back of the patient’s ID card under the heading Prior Authorization for the appropriate contact information and submission.
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| Speech-Generating Devices | Authorization is required. Providers should complete the Durable Medical Equipment (DME) Authorization form, and fax it to 816.257.3255 or 816.257.3515. For assistance, call 800.821.6136, ext. 3100. |
| Cancer Treatment — non-surgical | Authorization is required. To obtain preauthorization, providers should log in to oncohealth.us, select Provider Login dialog box and select GEHA. If you experience any issues using the oncohealth.us site or if you need access credentials for the portal, please contact OncoHealth Client Support at 888.916.2616. If you choose an evidence-based treatment, you will receive an immediate authorization approval. If you wish to submit a customized treatment plan, you may do so. However, customized plans require special review and may delay your authorization. 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 not required. However, GEHA does need the first date the member received dialysis for end-stage renal disease outpatient dialysis services. Providers should download a Dialysis Notification form, complete it and fax it to 816.257.3255. For assistance, call 800.821.6136, Ext. 3100. For inpatient care, 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. For cranial helmets, legible pictures with supporting documentation, medical records demonstrating cranial dimensions, prior therapies and response to such therapies can be mailed to GEHA Medical Management at PO Box 21542, Eagan, MN 55121. These supplies and equipment do not require authorization:
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| Genetic Testing | Authorization is required. Online authorization from evicore.com is required. Before starting the online authorization process, providers should download the Quick Reference Guide to Genetic Testing (PDF) and then proceed to evicore.com. For assistance, call 866.879.8317. |
| Hospital — Medical/Surgical Inpatient Care | Authorization is required. Providers/hospitals should call GEHA at 888.720.4342 to obtain prior authorization. Please fax clinicals to 816.257.3551. 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. |
| Orthotics and Prosthetics | Authorization is required for some orthotics and prosthetics. Orthotics: Call GEHA at 800.821.6136, Ext. 3100. 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. 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 required for pain management. Providers should download a Pain Management Authorization form, complete it and fax it (along with supporting documents) to 816.257.3515 or 816.257.3255. For assistance, call GEHA at 800.821.6136, Ext. 3100. |
| 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
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Authorization is required. Ask your provider to call eviCore at 866.879.8317 or visit evicore.com before scheduling the procedure. 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 is required. Providers should call OrthoNet at 877.304.4419; fax: 877.304.4409. For assistance, call 800.821.6136, Ext. 3100. |
| Skilled Nursing: Outpatient Includes Home Skilled Nursing Care, IV Therapy, Total Parenteral Nutrition (TPN)/ Intradialytic Parenteral Nutrition (IDPN) |
Authorization is not required, effective Jan. 1, 2021, for Home Skilled Nursing, IV Therapy, TPN and IDPN. Note: Please refer to the Specialty Prescription Drug authorization. For services before Jan. 1, 2021, authorization is required. Please call GEHA at 800.821.6136, Ext. 3100. |
| Therapy Services: Physical, Occupational and Speech | Authorization is not required (effective Jan. 1, 2020) for Physical Therapy, Speech Therapy and Occupational Therapy for physical rehabilitation. |
| 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.
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| 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.
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| 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 Hyperbaric Oxygen Therapy, wound vacuum devices, 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.
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