VHP Community Care Authorization Grid

(Effective Date 1/1/2005)

For Dental Services contact Doral Dental at 1-888-233-5935

For Mental health services or Chemical dependency contact Premier Behavioral Health at 1-800-325-7864

For Pharmacy services contact First Health at 1-866-434-5524

For Transportation contact 1-877-883-2889

For Home Healthcare, home infusion, hospice, prosthetics and DME supplies contact Windsor HomeCare Network at (615) 371-0433 or 1-800-793-3684.

Office visits to in-network Physician Specialists - no authorization required

All elective out-of-network treatment/services require an authorization

Procedures/Services	Authorization Status
Procedures/Services	Yes	No	Not Covered
30-day event monitor		x
Allergy serum/injections		x
Allergy testing		x
Ambulance (non-emergency)	x
Amniocentesis	x
Angiography/lymphangiography (75600-75893)		x
Barium swallow		x
Bone scan		x
Cardiac rehabilitation (includes professional)	x
Chemical dependency (see above)	x
Chemotherapy/radiation therapy	x
Chiropractic services	x
CT scan		x
CT scan - ultra fast and CT angiography	x
Cystometry		x
Developmental evaluation (medical evaluation and treatment are covered; educational evaluation and services are not covered)	x
DEXA/bone densitometry Performed in a provider's office Performed at facility, outpatient	x	x
Dialysis (at a par-facility)		x
DME Supplies (see above)	x
DME in provider office-attached list does not need additional authorization		x
Drugs, injectable (special order drugs only-e.g. synvisc, synagis, cancer medications, etc)	x
Echocardiogram (includes transesophageal)		x
Electrocardiogram (ECG), includes Tilt table (93360)		x
Electroencephalogram (EEG), simple (95812, 95816, 95819)		x
Electromyogram (EMG)		x
Emergency room/urgent care center (In Network facility)		x
Endoscopy (colonoscopy, EGD, bronchoscopy with bx, flex sig-office or outpatient facility)		x
Epidural steroid injections		x
Growth hormones	x
Hearing aids TennCare children under age 21, using an In-Network provider TennCare children under age 21, using a non-par provider Hearing aids for adults over age 21 are not covered per the TennCare contract.
		x
	x
			x
Hepatitis/Varicella, under age 19		x
Home healthcare (see above)	x
Home infusion (see above)	x
Hospice (see above)	x
Inpatient admission/observations/labor checks	x
Infertility treatment			x
In vitro fertilization			x
IV pyelogram		x
Laryngoscopies		x
Laboratory		x
Laser therapies (office)	x
Magnetic resonance angiography (MRA)	x
Magnetic resonance imaging (MRI)		x
Moh's surgery	x
Myelogram		x
Nerve conduction studies		x
Neuro-diagnostic testing	x
Non-participating providers	x
Nuclear studies, simple (positron emission tomography (PET), tomographic (SPECT) scans, and provision of radio pharmaceuticals may not be covered and would require authorization)(Also see PET Scans)		x
Office Visits to Physician Specialists (participating and within member's panel) All non-physician visits (Examples include PT, OT, ST, dietary, audiology, etc.) Chiropractic visits		x
	x
	x
Organ transplantation, including evaluation	x
Orthotics (coverage is limited to medically necessary orthotics for patients with diabetes mellitus)	x
Outpatient surgery	x
Pacemaker checks		x
Pain clinic visit Facility based Office based	x
Pain clinic visit Facility based Office based		x
PET Scans	x
Prosthetics (see above)	x
Pulmonary rehabilitation	x
Radiologic imaging, simple (participating, outpatient or office; specialized procedures are listed separately)		x
Rehabilitation, outpatient (physical, occupational, speech and other rehabilitation therapies)	x
Skilled nursing facility	x
Sleep studies	x
Speech evaluation medical evaluation and treatment are covered; educational evaluation and services are not covered)	x
			x
Stress tests (including thallium studies)		x
Synvisc injections - must have pre-certification for injection in office.	x
Termination of pregnancy (covered only in cases or rape, incest, or imminent threat to mother's life)	x		x
TMJ disorders (diagnosis and treatment)	x
UGI/barium enema		x
Ultrasound, obstetric first two, no auth required; third and subsequent require prior approval in normal pregnancy High Risk Pregnancy - No authorization required	x	x x
Vaccines not covered for travel no authorization needed for routine vaccination			x
		x
Well woman exam		x
Wound center	x

Durable Medical Equipment, Prosthetics, Orthotics and other equipment dispensed by physician offices

To qualify as durable medical equipment an item must withstand repeated use, be primarily and customarily used to serve a medical purpose, be generally not useful to a person in the absence of sickness or injury, and be appropriate for use in the home.

The following durable medical equipment items are covered without authorization when dispensed from the physician's office. The identified codes are used for billing. All other codes will be denied because all other covered durable medical equipment must be obtained from an In-Network Provider. For Coverage information call our Member Services Department at (615) 782-7878.

Product Description	Billing Code
Splint (hand and wrist)	A4570
Universal cradle arm sling	A4565
Canvas cock-up wrist splint, lace-up front with Velcro closure	A4570
Uni-fit wrist splint, cock-up style	A4570
Cervical pillow	E0943
Cervical collar-foam	L0120
Cervical collars-semi rigid, adjustable	L0140
Straight cane-adjustable or fixed	E0100
Quad cane	E0105
Crutches, aluminum, forearm	E0114
Crutches, wood, underarm	E0112
Crutches, aluminum, forearm	E0110


	VHP Community Care
	7100 Commerce Way , Suite 285
	Brentwood, TN 37027
	(615) 782-7800