Services that require prior authorization
Your Health Care Provider must obtain Prior Authorization from Medica before SSM Health Employee Health Plan will cover certain procedures or services. Examples of procedures and services that need Prior Authorization are listed below. This is NOT a complete list. You should contact member services at (877) 274-4693 (TTY: 711) or at understanding prior authorization to verify whether a procedure or service requires Prior Authorization.
Examples of procedures/services requiring Prior Authorization:
- Certain organ and blood and marrow transplant services - this Prior Authorization must be obtained before the transplant workup is initiated;
- In-network benefits for services from non-network providers, with the exception of emergency services;
- Certain reconstructive or restorative surgery procedures;
- Certain Drugs, biologics and biosimilars;
- Certain home health care services;
- Certain durable medical equipment;
- Certain outpatient surgical procedures;
- Certain imaging services;
- Non-emergency licensed air ambulance transportation; and
- Skilled nursing facility services.
