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Prior-Auth and Pre-Cert Information

  • ConnectCare Prior Authorization List

REQUIRED PRE-CERTIFICATION LIST as of 10/15/25

 

  • ALL Inpatient Admissions
  • Home Health Care- G0151, G0152, G0153, G0156, G0299 (excluding G0300, G0157)  home IV infusions and hospice Q5001
  • Mental Health/Substance Abuse treatment: Residential and PHP
  • ABA for autism: 97153, 97155, 97156
  • Abdominoplasty: 15847
  • Blepharoplasty: 15820-15823, 67916, 67917, 67923, 67924
  • Botox: J0585-J0588, 46505, 52287, 64611-64617, 64642-64647, 64650, 64653, 67345, 95873, 95874
  • Calcium Scoring by CT: 75571
  • Cardiac Multislice CT: 75572-75574
  • Cochlear Implant: 69930, L8614
  • Collagen Cross-Linking for Keratoconus: 0402T
  • Colonoscopy screening for high risk individuals under 45 years old: G0105
  • Dental hospital & anesthesia charges: 00170, 41899
  • Gamma Knife: 61796-61800, 63620-63621, 77371-77373
  • Gastric surgeries for Obesity: 43633, 43644, 43645, 43647, 43659, 43770‐43775, 43846, 43860
  • Gender Affirming Surgery, all types
  • Genetic Testing except for BRCA and prenatal screenings 81420 and 81507 ONLY
  • Mandible Osteotomy: 21196‐21199, 21145-21147
  • Maxillary Osteotomy: 21206
  • Rentals except oxygen and CPAP, and all DME over $ $1000
  • Otoplasty: 69300
  • Pain Management (Dx of TMJ is not covered)
  • Panniculectomy: 15830
  • PET scans: 78459, 78491, 78492, 78608, 78811-78816
  • Ptosis Repair: 67904, 67924
  • Reduction Mammoplasty: 19318
  • Rhinoplasty: 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462
  • RSV Treatment (Synagis): 90378
  • Septoplasty: 30520
  • TMS Transcranial Magnetic Stimulation: 90867-90869
  • Uvulopalatoplasty: 42145
  • Varicose Vein treatment: 36465, 36466, 36470, 36471, 36473‐36479, 36482, 36483, 37500, 37700-37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799

 

 

Request Pre-certification via the Pre-certification form found at https://www.connectcare.com/for-providers (including clinicals) to ConnectCare via fax at 989-839-1679

 

COMMON SERVICES THAT DO NOT REQUIRE PRIOR AUTHORIZATION

 

 

  • Genetic Testing  for BRCA and Prenatal screenings 81420 and 81507 (Note: all other types of Genetic Testing require prior authorization)
  • Cardiac/EP procedures do not require pre-cert (Ex: cardiac cath, cardiac ablation, pacemakers) as long as they are Outpatient.
  • DME rentals for home oxygen, CPAP, nebulizers & bilirubin lights
  • Orthotics
  • Imaging does not require pre-cert (Exceptions: Cardiac CT and PET scans do require prior authorization)
  • IV infusions (chemo, immunology agents such as IVIG, Ocrevus, Remicade, Rituxan, etc.) given in infusion centers do not require pre-cert.
  • Mental Health/Substance Abuse Intensive Outpatient (IOP) treatment (Note: Residential and PHP treatment do require prior authorization)
  • Palliative Care
  • Radiation therapy (Exception: Gamma Knife does require prior authorization)
  • Sleep studies
  • Wound Care Centers including debridement (Exception PICO NPWT, 97607, outpatient application only does require prior authorization)
  • Outpatient procedures do not generally need pre-cert except those listed on the Pre- Cert Required List
  • Vaginal deliveries with less that 48 hour stay, and Cesarean with less than 72 hour stay.

Common Outpatient Procedures - Prior Auth is not required unless otherwise noted:

  • Urology procedures (use of Botox requires prior authorization)
  • Foot and ankle surgeries (Dx of flat foot not covered)
  • Dermatology procedures, such as Mohs procedure for skin cancer
  • All eye, knee and spinal injections
  • All pain management procedures (Dx of TMJ not covered)
  • All Outpatient IR procedures including angiograms, angioplasties, stents

If the service you are looking for is not listed in this information, please reach out to ConnectCare Case Management by calling 989-839-1629 option 3.

ConnectCare

Utilization Management

ConnectCare's Utilization Management Staff is available to address questions and issues related to case management and utilization by using the telephone or fax numbers listed below.

ConnectCare Medical Management
6810 Eastman Avenue
Midland, MI 48642
Toll free: 888-646-2429
Local: 989-839-1629
Fax: 989-839-1679
 
Hours of Operation
8:00 a.m. - 12:00 p.m.
1:00 p.m. - 5:00 p.m.
Monday - Friday (Eastern Time)

After normal business hours, inbound communications and information may be relayed via fax, confidential voice mail or electronic mail. All precertification requests and/or communications received after normal business hours are returned on the next business day and communications received after midnight on Monday through Friday are responded to on the same business day.