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Authorizations/Precertifications for FEHB and PSHB HDHP, Standard and High health members

Important note: The authorization information on this page is for G.E.H.A's FEHB/PSHB HDHP, Standard, and High health plan members. For other health plans, visit Authorizations/Precertifications for FEHB/PSHB Elevate and Elevate Plus health members.

For Providers – To submit an authorization or for more information and help with authorizations, please access the Provider portal

For Members – For more information and help with authorizations, please access the MyGEHA member portal

General information

  • Authorization requirement: G.E.H.A, like other federal health plans, requires providers to obtain authorization before some services and procedures are performed.
  • Reference: More information can be found in the G.E.H.A plan brochure. For quick reference, see the G.E.H.A member's ID card.
  • Clinical guidelines: The sources of our clinical guidelines can be found on our Sources of Utilization Management Criteria (PDF).
  • Primary payer: If Medicare or another group health insurance policy is the primary payer for these services, you do not need to obtain authorization.

Emergency admissions
If 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:

  • Action required: You, your representative, the doctor, or the hospital must call G.E.H.A within two business days following the day of the emergency admission, even if you have been discharged from the hospital.
  • Responsibility: Although your physician or hospital will precertify your stay, it is your responsibility to ensure that precertification is complete.
  • Failure to precertify: Failure to precertify inpatient stays could result in a benefits reduction.
  • International admissions: It is not necessary to precertify hospital admissions outside the United States. For more details on your G.E.H.A coverage when traveling, click Outside the United States.

Contact information

  • Benefits and eligibility: Call G.E.H.A's Customer Care department at 1-877-460-7673.
  • Prior authorization: Refer to the back of the patient's ID card for the appropriate contact information and submission.

Benefits requiring authorization

Authorization is required for all services addressed below.

Please scroll to the bottom of the page for details regarding obtaining prior authorization on the following services:

  • Cancer treatment
  • Fertility procedures and medications
  • Prescription drugs
  • Specialty prescription drugs
Benefits requiring authorization
Category Procedures
Applied Behavioral Analysis (ABA) therapy Applied Behavioral Analysis (ABA) therapy
Arthroplasty Including revisions to a prior arthroplasty
Back and spinal procedures Discectomy/fusion, intrathecal pump insertion for pain management (morphine pump, baclofen pump), neurostimulation-spinal
Bariatric surgery Bariatric and metabolic surgical procedures (obesity surgery)
Behavioral health facilities and programs (includes mental health and substance use disorders) Acute inpatient, Sub-acute inpatient, Residential Treatment Centers (RTC), Intensive Outpatient Programs (IOP), Partial Hospitalization Programs (PHP)
Bone growth stimulators Bone growth stimulators
Breast and chest surgeries Breast reconstruction (non-cancer), gynecomastia treatment (cosmetic), mammoplasty reduction
Cardiac and vascular procedures Ablative treatment of venous insufficiency including sclerotherapy and microphlebectomy, implantable cardiac monitoring, nuclear medicine studies including nuclear cardiology, transcatheter arrhythmia ablation, transcatheter aortic and pulmonary valve repair or replacement
Cartilage implants Autologous Cultured Chondrocytes (ACI), osteochondral grafting
Cellular and gene therapy Cellular and gene therapy
Cochlear implants Cochlear and auditory implants and procedures
Durable medical equipment Durable medical equipment (DME)
Experimental/Investigational Surgery or treatment, including clinical trials
Genetic testing Genetic testing
Hysterectomy Except for diagnosis of cancer
Medical/Surgical facilities Acute inpatient, Long-Term Acute Care (LTAC), Acute Rehabilitation Facility (ARF), Skilled Nursing Facility (SNF)
Neurostimulation Neurostimulation, including devices and implantation procedures for cranial, gastric, peripheral, spinal or vagus nerve stimulation
Non-emergency air ambulance Non-emergency air ambulance transportation
Orthognathic surgery Jaw surgery, including TMJ
Orthopedic devices Orthopedic devices and prosthetic devices
Prostate implants, destruction and removal Prostate implants, destruction and removal
Psychological and neuropsychological testing Exceeding 8 hours/year
Radiology (high tech outpatient radiology/imaging) • CT — Computerized Axial Tomography
• LDCT — Low-dose computed tomography
• MRI — Magnetic resonance imaging
• MRA — Magnetic resonance angiography
• NC — Nuclear cardiac imaging studies
• PET — Positron emission tomography
Reconstructive or potential cosmetic procedures Abdominoplasty, panniculectomy, lipectomy, eyelid surgery, brow lift, rhinoplasty, scar revisions, surgical correction of congenital anomalies
Sleep studies (in-lab) Attended or performed in a health care facility (home sleep studies do not require preauthorization)
Speech devices Speech-generating devices
Surgical treatment of airway obstructions, including for sleep apnea Uvulopalatopharyngoplasty (UPPP), hyoid myotomy and suspension, Functional Endoscopic Sinus Surgery (FESS), sinuplasty, correction of choanal atresia and intranasal synechia
Surgical treatment of gender dysphoria Surgical treatment of gender dysphoria
Transplants Organ and tissue transplant procedures
Wound care (outpatient) Advanced wound therapy
Specific instructions for authorization on the following services:
Cancer treatment — non-surgical outpatient cancer treatment including chemotherapy, radiation, and cell and gene therapy
  • Contact: Providers should log in to oncohealth.us and select Provider Login dialog box and select G.E.H.A. 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 1-888-916-2616.
  • Approval: Immediate authorization for evidence-based treatment. Customized plans require special review. Please note, some treatments may have applicable G.E.H.A coverage policies that can be found at G.E.H.A's Provider Resource Center.
  • Please note: Based on the G.E.H.A 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 1-855-240-0536.
Fertility procedures and medications
  • Contact: Providers should contact Progyny at 1-866-960-3951 or visit progyny.com.
  • Review:
    • Artificial insemination procedures (intravaginal insemination, intracervical insemination, intrauterine insemination)
    • Harvesting of sperm/eggs and storage of sperm/embryos/eggs for iatrogenic infertility diagnosis
    • Medications prescribed as part of fertility preservation and treatment of infertility
Prescription drugs
  • Contact: CVS Caremark at 1-855-240-0536 for specialty and certain prescription drugs; for growth hormone therapy, call G.E.H.A at 1-800-821-6136
  • Review: Some medications must be approved before they are a covered benefit.
    • Certain prescription drugs
    • Certain specialty prescription drugs
    • Certain drugs to treat infertility
    • Botox injections
    • Injectable drugs for arthritis, psoriasis or hepatitis
    • Injectable hematopoietic drugs (drugs for anemia, low white blood count)
    • Growth hormone therapy (GHT) — For preauthorization, call G.E.H.A at 1-800-821-6136
  • 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 section 5(f) of the G.E.H.A Plan Brochure.
Specialty prescription drugs
  • Contact: Contact CVS Caremark at 1-855-240-0536.
  • Review: Certain specialty prescription drugs to treat severe medical conditions and are usually administered by injection or infusion. See Specialty Drug Benefits in section 5(f) of the G.E.H.A Plan Brochure.