Medical Prior Authorization Guidelines

Our prior authorization guidelines provide an up-to-date list of all services requiring prior authorization. Prior authorizations are processed either through our provider portal or eviCore. Check out our prior authorization lists below to identify which services require submission.

eviCore CPT List - February 2026

Urgent and Expedited Requests Tip Sheet

To ensure timely processing, please review the criteria and timelines for submitting Urgent or Expedited authorization requests across all lines of business.

Definitions

Urgent Care Services: services needed within 24 hours to prevent the likely onset of an Emergency Medical Condition.

Urgent Medical Condition: A serious illness or injury that must be treated within 24 hours to avoid becoming a crisis or emergency. Also includes services needed to prevent hospital admission or discharge delays.

Requests that do not meet these definitions will be processed under standard timeframes.

Per CMS Guidelines:

If an expedited request is denied, the Jefferson Health Plans will:

• Transfer the request to the standard review process;
• Provide verbal notice of the denial promptly;
• Issue a written notice within 3 calendar days of the verbal notice.

Drugs and Biologics Turn-Around Times

• Medicaid/CHIP Drugs: 24 hours to the minute
• Medicare Drugs: 72 hours to the minute
• Medicare Drugs (Expedited): 24 hours to the minute
• ACA Drugs: 15 calendar days

Non-Drug Turn-Around Times

• Utilization Management - Medicaid/CHIP Standard: 2 business days for OP ancillary
• Utilization Management - Medicaid/CHIP Urgent: 24 hours
• Utilization Management - Medicare: 14 calendar days
• Utilization Management (no clinical) - ACA: 72 hours
• Utilization Management (with clinical) - ACA: 24 hours
• Pre-cert - Medicaid: 2 business days
• Pre-cert - Medicare: 14 calendar days
• Pre-cert (Standard) - ACA: 15 calendar days
• Pre-cert (Urgent) - ACA: 2 business days
• Retro - All: 30 calendar days

Medicaid Medical Prior Authorization Guidelines

Prior Authorization Guidelines and eviCore services – Medicaid. The services listed here require prior authorization as a condition of payment. Important note: All eviCore prior authorizations are submitted through the eviCore website, using a simple, easy-to-use application. Proper submission ensures timely processing.

Submit through the eviCore portal:

• Advanced Radiology Services (CT, MRI, MRA, PET scans, stress echocardiography, cardiac nuclear medicine imaging, 3D Imaging)
• Automatic Implantable Cardioverter Defibrillators (AICD)
• Chiropractic Therapy
• Diagnostic Cardiac Catheterization
• Interventional Pain Management
• Medical Oncology and Supportive Drugs Including Chemotherapy as Home Infusion
• Outpatient Spine and Joint and Back Surgeries
• Outpatient Therapy Services: Physical Therapy (PT), Occupational Therapy (OT), or Speech Therapy (ST)
• Permanent Pacemakers
• Pulmonary Artery Pressure Sensor Implantation (Wireless)
• Radiation Oncology

Submit to eviCore Submit to Provider Portal
Submit through the Provider Portal:

• Acute Rehabilitation Admissions
• Air Ambulance
• Some Potentially Cosmetic Services
• Durable Medical Equipment (DME) over $500 and all DME rentals
• Elective Hospitalization
• Endovascular Ablation of Varicose Veins
• Facility-Based Sleep Management
• Home Infusion Medications (Non-Oncology)
• Home Services
• Hyperbaric Oxygen Therapy
• Inpatient Hospice
• NICU and/or Detained Newborns
• Non-Preferred Glucose Monitors
• Outpatient Vascular Surgeries
• Pharmacy-Specific Drug Prior Authorizations: Drugs Requiring Authorization – Drug-Specific Prior Authorizations 2024 (Medicare)
• Prosthetics/Orthotics – over $500
• Services, Procedures, Items, or Drugs Considered to be New or Emerging Technology
• Services/Procedures Performed by Non-Participating Providers
• Skilled Nursing Admissions
• Transfer to Non-Participating Facilities
• Vascular Surgeries*
• Whole Genome and Whole Exome Sequencing

*Vascular surgery includes AAA resection, grafts and endovascular repair; Carotid angioplasty, endarterectomy and stent; Peripheral artery bypass and endovascular intervention; Renovascular angioplasty; and Thoracic and Thoracoabdominal aortic aneurysm repairs.

CHIP Medical Prior Authorization Guidelines

Prior Authorization Guidelines and eviCore services – CHIP. The services listed here require prior authorization as a condition of payment. Important note: All eviCore prior authorizations are submitted through the eviCore website, using a simple, easy-to-use application. Proper submission ensures timely processing.

Submit through the eviCore portal:

• Advanced Radiology Services (CT, MRI, MRA, PET scans, stress echocardiography, cardiac nuclear medicine imaging, 3D Imaging)
• Automatic Implantable Cardioverter Defibrillators (AICD)

Submit to eviCore Submit to Provider Portal
Submit through the Provider Portal:

• Acute Rehabilitation Admissions
• Air Ambulance
• Some Potentially Cosmetic Services
• Durable Medical Equipment (DME) over $500 and all DME rentals
• Elective Hospitalization
• Endovascular Ablation of Varicose Veins
• Ground Transportation (except Behavioral Health)
• Hearing Aids and related accessories $500 and over
• Home Services
• Inpatient Hospice
• NICU and/or Detained Newborns
• Non-Oncology High-Cost Injectable Drugs Including Gene Therapy (Policy Bulletin Library. Scroll down to the Drug section)
• Non-Preferred Glucose Monitors
• Pharmacy-Specific Drug Prior Authorizations: Drug-Specific Prior Authorizations 2024 (Medicaid/CHIP)
• Services, Procedures, Items, or Drugs Considered to be New or Emerging Technology
• Services/Procedures Performed by Non-Participating Providers
• Skilled Nursing Admissions
• Transfer to Non-Participating Facilities
• Whole Genome and Whole Exome Sequencing

Medicare Medical Prior Authorization Guidelines

Prior Authorization Guidelines and eviCore services – Medicare. The services listed here require prior authorization as a condition of payment. Important note: All eviCore prior authorizations are submitted through the eviCore website, using a simple, easy-to-use application. Proper submission ensures timely processing.

Submit through the eviCore portal:

• Advanced Radiology Services (CT, MRI, MRA, PET scans, stress echocardiography, cardiac nuclear medicine imaging, 3D Imaging)
• Automatic Implantable Cardioverter Defibrillators (AICD)
• Chiropractic Therapy
• Diagnostic Cardiac Catheterization
• Interventional Pain Management
• Medical Oncology and Supportive Drugs Including Chemotherapy as Home Infusion
• Outpatient Spine and Joint and Back Surgeries
• Outpatient Therapy Services: Physical Therapy (PT), Occupational Therapy (OT), or Speech Therapy (ST)
• Permanent Pacemakers
• Pulmonary Artery Pressure Sensor Implantation (Wireless)
• Radiation Oncology

Submit to eviCore Submit to Provider Portal
Submit through the Provider Portal:

• Acute Rehabilitation Admissions
• Air Ambulance
• Some Potentially Cosmetic Services
• Durable Medical Equipment (DME) over $500 and all DME rentals
• Elective Hospitalizations
• Endovascular Ablation of Varicose Veins
• Facility-Based Sleep Management
• Home Services
• Hyperbaric Oxygen Therapy
• Non-Oncology High-Cost Injectable Drugs (Provider Portal Drugs Requiring Authorization - Policy Bulletin Library. Scroll down to the Drug section)
• Outpatient Vascular Surgeries
• Pharmacy-Specific Drug Prior Authorizations: Drugs Requiring Authorization – Drug-Specific Prior Authorizations 2024 (Medicare)
• Prosthetics/Orthotics – over $500
• Provider Portal Drugs Requiring Authorization
• Services, Procedures, Items, or Drugs Considered to be New or Emerging Technology
• Services/Procedures Performed by Non-Participating Providers
• Skilled Nursing Admissions
• Transfer to Non-Participating Facilities
• Vascular Surgeries*
• Whole Genome and Whole Exome Sequencing

*Vascular surgery includes AAA resection, grafts and endovascular repair; Carotid angioplasty, endarterectomy and stent; Peripheral artery bypass and endovascular intervention; Renovascular angioplasty; and Thoracic and Thoracoabdominal aortic aneurysm repairs.

Individual and Family Plans Medical Prior Authorization Guidelines

Prior Authorization Guidelines and eviCore services – Individual and Family Plans. The services listed here require prior authorization as a condition of payment. Important note: All eviCore prior authorizations are submitted through the eviCore website, using a simple, easy-to-use application. Proper submission ensures timely processing.

Submit through the eviCore portal:

• Advanced Radiology Services (CT, MRI, MRA, PET scans, stress echocardiography, cardiac nuclear medicine imaging, 3D Imaging)
• Automatic Implantable Cardioverter Defibrillators (AICD)
• Diagnostic Cardiac Catheterization
• Interventional Pain Management
• Medical Oncology and Supportive Drugs Including Chemotherapy as Home Infusion
• Outpatient Spine and Joint and Back Surgeries
• Permanent Pacemakers
• Pulmonary Artery Pressure Sensor Implantation (Wireless)
• Radiation Oncology

Submit to eviCore Submit to Provider Portal
Submit through the Provider Portal:

• Acute Rehabilitation Admissions
• Air Ambulance
• Some Potentially Cosmetic Services
• Durable Medical Equipment (DME) over $500 and all DME rentals
• Elective Hospitalizations
• Endovascular Ablation of Varicose Veins
• Home Infusion Medications (Non-Oncology)
• Home Services
• Hyperbaric Oxygen Therapy
• Inpatient Hospice
• Non-Oncology High-Cost Injectable Drugs (Provider Portal Drugs Requiring Authorization - Policy Bulletin Library. Scroll down to the Drug section)
• NICU and/or Detained Newborns
• Outpatient Vascular Surgeries
• Pharmacy-Specific Drug Prior Authorizations: Drugs Requiring Authorization – Drug-Specific Prior Authorizations 2024 (Medicare)
• Prosthetics/Orthotics – over $500
• Services, Procedures, Items, or Drugs Considered to be New or Emerging Technology
• Services/Procedures Performed by Non-Participating Providers
• Skilled Nursing Admissions
• Facility-Based Sleep Management
• Transfer to Non-Participating Facilities
• Vascular Surgeries*
• Whole Genome and Whole Exome Sequencing

*Vascular surgery includes AAA resection, grafts and endovascular repair; Carotid angioplasty, endarterectomy and stent; Peripheral artery bypass and endovascular intervention; Renovascular angioplasty; and Thoracic and Thoracoabdominal aortic aneurysm repairs.