PHP requires prior authorization for certain services that are provided to our members, including off-plan referrals. Please familiarize yourself with these services and requirements. Forms for submitting prior authorization requests can be found under the Forms section.
Download our PDF for a complete list of services requiring prior authorization.
Below is a listing of our outpatient procedure reviews for a select group of procedure codes. These procedure codes require pre-certification from your office and will be subject to a review process by our Medical Management staff to ensure quality and appropriateness of care to our membership receiving medical services.
Please review the list below of the selected procedures that will be affected by this review process.
Procedure: Nasal fracture and/or dislocation
Codes: 21310, 21315, 21320, 21325, 21330, 21335, 21336, 21337
Here are additional procedure codes that will be subjected to outpatient procedure reviews. These codes have been considered as non-covered services as they are performed for cosmetic reasons
Codes: 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462
For further information regarding outpatient procedure reviews, please contact PHP Medical Management at (260) 432-6690, ext. 12.
A referral to a non-participating specialty doctor may be obtained if a uniquely specialized procedure is medically necessary and not performed by any participating doctors. This process must be requested by the participating doctor and approved by PHP, in writing, prior to receiving the services. It is the member's responsibility to notify us of the initial appointment date, or a change to the date they were given by the physician.
If the visit results in a recommendation for further treatment such as therapy, durable medical equipment, additional testing or surgery, the member must notify us prior to receiving these services. The non-participating specialty doctor you were referred to should send claims associated with the visit to:
PO Box 2359
Fort Wayne, IN 46801-2359
After the visit, the non-participating specialty doctor should send the treatment plan summary to PHP's vendor partner:
FAX: (863) 333-4417
Please notify PHP of all multiple births and high risk pregnancies by calling PHP Medical Management at (260) 432-6690 or (800) 982-6257, ext. 12. For prior authorization needs, please contact PHP's vendor partner Vālenz Health via fax at 863-333-4417. The following guidelines are associated with maternity claims submission:
GLOBAL MATERNITY SERVICES
Services provided in uncomplicated maternity cases include antepartum care, delivery and postpartum care.
Antepartum Care includes:
- physical examinations
- initial and subsequent history
- blood pressure
- recording weight
- routine chemical urinalysis
- fetal heart tones
- monthly visits up to 28 weeks gestation
- biweekly visits up to 36 weeks gestation
- weekly visits until delivery
Delivery Services include:
- hospital admission
- admission history and physical examination
- induction of labor
- management of uncomplicated labor
- vaginal delivery (with or without episiotomy or forceps)
- cesarean delivery
Postpartum Care includes:
hospital and office visits following vaginal or cesarean delivery
- 59400 Routine obstetric care including antepartum care vaginal delivery and postpartum care.
- 59510 Routine obstetric care including antepartum care, cesarean delivery and postpartum care.
- 59610 Routine obstetric care including antepartum care, vaginal delivery and postpartum care after a previous cesarean delivery. (VBAC)
- 59618 Routine obstetric care including antepartum care, cesarean and postpartum care following attempted vaginal delivery after previous cesarean delivery.
ANTEPARTUM CARE ONLY
Antepartum or prenatal care includes the initial and subsequent histories, physical examinations, recording of weight, blood pressures, fetal heart tones, and routine chemical urinalysis.
- 59425 Antepartum care only, 4 - 6 visits.
- 59426 Antepartum care only, 7 or more visits.
Although these codes are intended to indicate a certain number of visits, PHP is set up to pay these codes per occurrence. When you submit claims for Antepartum care alone, be sure to indicate the specific date and number of times you saw the patient. This will assure proper payment.
Break-out of services is required when a PHP member:
- has more than one physician or physician group providing services during her maternity care
- change in insurance plan during her pregnancy
- has miscarried
The individual codes listed below are to be used when breaking out services:
- E/M code 1-3 OB visits CPT 59425 4-6 OB visits*
- CPT 59426 7 or more OB visits*
- CPT 59410 Uncomplicated vaginal delivery including postpartum care
- CPT 59515 Uncomplicated cesarean delivery including postpartum care
- CPT 59409 Vaginal delivery only
- CPT 59514 Cesarean delivery only
- CPT 59430 Post Partum care only *
The individual office visit codes require a range of service dates. The number of units in box F should indicate the number of visits in the range and include all services as outlined in "Antepartum Care.”
MULTIPLE BIRTH DELIVERIES
Contact PHP for assistance in correct coding of multiple birth deliveries