Prior Authorization request means a service Authorization Request by the Member, or a provider on the Member’s behalf, for coverage of a service, before such service is provided to the Member shall require review for medical necessity. To help ensure your claims are paid without delay, please follow Affinity’s updated requirements for prior authorizations. Affinity recently changed these requirements. Prior authorization is required for services listed in this document.
Affinity Health Plan is pleased to announce an expanded partnership with eviCore healthcare to provide authorization services for our eligible members. EviCore is currently managing the authorization process for radiology services for Affinity Health Plan members. Effective January 1st, 2017, the following services will also be managed by eviCore, Radiation Therapy, Ultrasound, Sleep Management, Physical Therapy(PT), Occupational Therapy (OT), Speech Therapy (ST) and Cardiac Imaging and radiology services. For more information and codes related to these services, please visit https://www.evicore.com/healthplan/Affinity.
Please note: In response to questions we have received from our provider community with regards to Affinity Health Plan’s recently expanded partnership with eviCore Healthcare for authorization services, please note some points of clarification for the following services:
For a routine pregnancy, the first two ultrasounds – nuchal translucency (76813) and fetal anatomy survey (76805) – do not require prior authorization. Any additional ultrasounds will require prior authorization.
The first ultrasound for any one specific condition (example: pelvic ultrasound for pelvic pain, thyroid ultrasound for a thyroid mass, renal ultrasound for hematuria) does not require a prior authorization. Any additional ultrasound for the same condition will require prior authorization.
Prior authorization is not required for the first six (6) visits within the benefit period. Visit Seven (7) and beyond will require prior authorization. Please refer to the specific program benefits for limitations.
Sleep Study Supplies
Prior authorization is required every 3 months
Out-of-network services or services rendered by a non-participating physician or provider continue to require prior authorization. Participating Affinity providers must refer to in-network providers and/or render services in in-network facilities.
All admissions through the Emergency Department require notification within 24 hours of the admission in order to obtain authorization for continued inpatient stay.
All Authorization Forms