FirstCare Authorization Guidelines

Certain services require authorization in order to be covered by FirstCare Health Plans. Authorization review is the process of determining the medical necessity of a proposed procedure, surgery or treatment—including prescribed drug intervention—relative to approved evidence-based medical criteria.

Authorization is required to ensure that a requested medical service is medically necessary and that the member will receive the benefits to which they are entitled under their plan.

Prior authorization requests must be received before the services are provided to the member. Failure of a network provider to contact FirstCare for the required prior authorization of services covered under the member’s plan and/or rendered prior to notifying FirstCare will relieve both FirstCare and the member from any financial responsibility for the service(s) in question.

FirstCare utilization management staff are available to answer questions about authorization requirements or processes at 1-800-884-4905 (Monday through Friday, 6 a.m. – 6 p.m. CT, and from 9 a.m. to 12 p.m. CT on weekends and holidays). Requests may be submitted online after logging in to the FirstCare Provider Self-Service portal. Requests may also be submitted via fax at 1-800-248-1852.

Additional Requirements

  • All services, even if authorized, are subject to the member’s benefit plan contract coverage and exclusions, eligibility and network design. Approvals are not a guarantee of coverage, as the member’s benefit plan contract may retroactively terminate at a future date. Benefit plan contract exclusions and current status of eligibility may be verified by logging into the FirstCare Provider Self-Service portal. Out-of-network providers are encouraged to contact FirstCare’s Customer Service with any questions regarding benefit limitations.
  • All transplant services require prior authorization.
  • Cosmetic procedures are not covered for most plans. Please refer to the member's plan documents—Evidence of Coverage (EOC) or Certificate of Insurance (COI)—for further details as some reconstructive procedures may be covered if medical necessity criteria are met.
  • Home Health Requirements

  • Prior authorization is required for home health services. Services may include home health aide, occupational therapy, physical therapy, skilled nursing, speech therapy and/or social work. Prior authorization is not required for physical or occupational therapy evaluation.
  • The first visit for newly ordered home Skilled Nursing and home Speech Therapy requires authorization but will not require a prior authorization. FirstCare will retrospectively approve the initial nursing evaluation visit and/or speech therapy evaluation when the written evaluation and plan of care is received—within four (4) business days. Any additional services rendered during those four business days will also be retrospectively reviewed.
  • Inpatient Authorization Requirements

  • Services or codes listed within this document require prior authorization and will have a separate authorization number. 
  • For acute levels of inpatient care, FirstCare requires notification within 24 hours (or next business day for holiday weekends).
  • If, in the judgment of the rendering provider, the care is of an emergency or urgent nature, medical necessity review is required after the care begins.
  • Notification is required for obstetrical (OB) delivery when an associated inpatient stay is expected to exceed 48 hours post vaginal delivery or 96 hours post-cesarean delivery. 
  • Prior authorization on/before services are rendered is required for Inpatient Rehabilitation, Skilled Nursing Facility (SNF), Long term Acute Care (LTAC).
  • Out-of-Network Provider/Facility Services

  • Referrals to out-of-network providers must be pre-authorized and may be covered by FirstCare when one or more of the following conditions are present:
  • Life threatening emergency situation exists and delivery of services is appropriate or timely;
  • Access to an in-network facility or service is not reasonably practical or possible;
  • Medically necessary, covered medical service is not available through an in-network Provider;
  • Service or care is available in-network, but not accessible; and/or
  • Service is available in-network, but there is a continuity of care concern for a new member (e.g. any high risk pregnancy in the second trimester, a pregnancy in the third trimester or any other situation which, in the judgment of the Medical Director warrants an out-of-network authorization to complete a particularly complex episode of care).
  • Exceptions: Emergency Services. Rendering Medicaid providers must have a TPI.
  • Behavioral Health Requirements

  • The following revenue codes for behavioral health services require authorization:  (This list is not all-inclusive)
  • Inpatient Behavioral Health (Revenue codes 100, 101, 110, 114, 124, 134, 144, 154, 204)
  • Inpatient Chemical Dependency/ Detoxification (Revenue codes 116, 126, 136, 156)
  • Partial Hospitalization (Revenue code 912)
  • Substance Abuse Intensive Outpatient (Revenue code 913)
  • Intensive Outpatient (Revenue code 905)
  • Substance Abuse Intensive Outpatient (Revenue code 906)
  • Mental Health Residential Treatment (Revenue code 1001)
  • Electroconvulsive Therapy (Revenue code 901)
  • Failure to obtain prior authorization for out-of-network services may result in a denial of payment for services rendered. Out-of-network providers should submit prior authorization requests by completing and faxing the FirstCare Prior Authorization Request Form.
  • Out-of-network providers must obtain an authorization before services are rendered to a FirstCare member. Please use the appropriate authorization form—located here—and submit your request via fax to 1-800-248-1852.
  • Up-to-date listings of services and codes requiring prior authorization can be found on this page under the "Resources" section on this page.
    NOTE:  Additional authorization requirements may be required for FirstCare STAR (Medicaid), CHIP, HMO, PPO, and FirstCare Advantage (Medicare).
  • All services that are considered experimental/investigational or potentially cosmetic require prior authorization.
  • Providers may contact FirstCare Health Plans to request a copy of the actual benefit provision, guideline, or other criteria on which a determination was made. For details on reaching out to FirstCare, please click here.
Providers are advised to leave their fax systems on at all times in order to receive correspondence from FirstCare (i.e. requests for additional clinical, options for peer-to-peer review, etc.) during and after business hours.

Preauthorization Code Search Tool

FirstCare in-network providers are encouraged to access the service code serach tool via the FirstCare Provider Self-Service portal to determine if preauthorization is required for a specified service. This tool allows you to quickly find out if services must be authorized.

  • Enter one or more valid CPT or HCPCS codes into the tool and it will provide direction as to whether or not preauthorization is required as well as any exceptions or special instructions for the code(s) entered.

Alternately, providers can view the individual preauthorization lists for durable medical equipment (DME), behavioral health, spinal care, and other general services under the 'Related Documents' section on this page.

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