Prior Authorization Requirements

Your Benefits

Some services need Prior Authorization through Partners Health Plan Utilization management. See below to learn more.

What services need Prior Authorization through PHP's Utilization Management?

The services below need Prior Authorization.

* Service requires authorization during Participant's 90-day continuity of care period.

Ambulatory Surgery Procedures*
- Abdominoplasty
- Blepharoplasty
- Mastoplexy
- Otoplasty
- Keloid & Scar Revisions
- Mammoplasty, Reduction or Augmentation
- Surgical Treatment of Gynecomastia
- ENT Procedures (Rhinoplasty, Septoplasty,
  Uvoluplasty, LAUP)
- Varicose Veins Treatment
- Ventral Hernias
- Bariatric Surgery
Home Health Care Services
- Does not includes CDPAS & PCA as IDT team will approve
- Initial Assessment – Nursing, OT, PT, Speech, Nutritional Counseling and Pulmonary Therapies no auth required.
Home Infusion Services
Inpatient Admissions*
- Acute Care Facilities, including Inpatient OBGYN
- Skilled Nursing Facilities / Nursing Home
- Behavioral Health Care Facilities
  - Elective Admissions
  - Urgent / Emergent Admissions
  - Substance Abuse and Rehabilitation
- Inpatient Rehabilitation Facilities
Medical Social Services*
Nerve Block / Epidurals*
Organ Transplant Evaluation & Services*
Rehabilitation Services – Outpatient
- Physical Therapy
- Occupational Therapy
- Speech Therapy
- Pulmonary & Cardiac Rehabilitative Therapy
- Nutritional Counseling
Radiology *
- MRI
- Functional MRI
- MRA
- PET
Private Duty Nursing
Outpatient Services *

(below services only)
- Chiropractic Services
  - No PA required for subluxation of spine.
  - Any other services require prior auth
- Podiatry – 4 Annual Visits
  - 4 routine visits covered per year without UM review.
  - All other podiatry visits will require UM approval
Other Services*
- Hyperbaric Oxygen Treatment
- Investigation & Experimental Treatment

How does a provider obtain Prior Authorization for these services?

Obtain the Prior Authorization Request Form

Prior Authorization Request Form

Complete the form and fax, along with all pertinent clinical information, to Utilization Management at 855-769-2509

Call Utilization Management if you have any questions at 855-769-2508

What services require Prior Authorization through Partners Health Plan Care Coordination Team?

Adult Day Health Care
Assertive Community Treatment
Continuing Day Treatment
Consumer Direction Personal Assistance Services (CDPAS)
DME / Prosthetics / Orthotics
Enteral / Parenteral Nutrition
Personalized Recovery Oriented Services
Personal Care Services
Personal Emergency Response Services
Office for People with Developmental Disabilities (OPWDD) Home and Community-Based (HCBS) Waiver Services

Contact Us

Partners Health Plan
2500 Halsey Street
Bronx, NY 10461

(855) PHP-LIVE or (855) 747-5483
TTY:711
8am-8pm, 7 days a week

855-747-5483 | TTY/TDD:711
Partners Health Plan is a managed care plan that contracts with Medicare and the New York State Department of Health (Medicaid) to provide benefits to Participants through the Fully Integrated Duals Advantage for Individuals with Intellectual and Developmental Disabilities (FIDA-IDD) Demonstration.

H9869_PHPWeb_Approved

The State of New York has created a Participant Ombudsman Program called the Independent Consumer Advocacy Network (ICAN) to provide participants free, confidential assistance on any services offered by Partners Health Plan. ICAN may be reached toll-free at 1-844-614-8800 (TTY users call 711, then follow the prompts to dial 844-614-8800) or online at icannys.org.