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Exclusions List | Out of Network Prior Authorization

The following services will not require out-of-network authorization:
 
  • Family Planning Services
    • Anything billed with family planning diagnosis codes
  • Vaccines and Administrative Services
    • Includes administration of medication and medication management
  • Dialysis
  • Emergency Room
  • Urgent Care
  • Ambulance/Emergency Transport Services
    • Prior authorization for out of network providers is required for fixed wing codes
  • Basic Radiology Services
  • High-tech Imaging (MRI, MRA, and PET scans)
    • Prior authorization for out of network providers is required for specialized radiation therapy
  • Basic Lab Services
    • Prior authorization for out of network providers is required for genetic and drug testing codes
    • Prior authorization for out of network providers is required for non-participating independent labs
  • Anesthesia Services
    • Prior authorization for out of network providers is required for pain management codes
  • Hearing Aids
  • Psychotherapy – Individual & Group
  • Psych Testing
  • Any service at Federally Qualified Health Center (FQHC) 
  • Any service at Rural Health Center (RHC)
  • Any service at Tribal Health Center (THC)
  • ESPDT Services
    • Will be reviewed for all members <21 years and not denied solely for OON, there must be a medical reason not to approve
Last Updated: 03/31/2025