Prior Authorization / Referral
Some covered services may need approval from Home State Health. This is called a Prior Authorization (PA). You do not need a paper referral from Home State Health to see a provider but your provider may need to request a prior authorization from Home State Health for a service to be approved.
Our prior authorization process will see many improvements. We will be more clear with processes, and we will reduce wait times for things like tests or surgeries. You will also see improved fairness with our PA process.
Our current PA process is NCQA certified. It meets many of the new law's standards. However, we see this as a time to continue improving our services.
You do not need a referral from your Primary Care Physician to see a specialist, and you do not need a referral for routine vision care, chiropractic services, or mental health / counseling services.
Below is a list of services that require prior authorization from Home State Health before your healthcare provider can proceed with treatment.
| SERVICES THAT REQUIRE A PRIOR AUTHORIZATION | PRIOR AUTHORIZATION REQUIRED FOR SOME OR ALL OF THE SERVICES? |
|---|---|
| Ambulatory Surgery Center | Some services require prior authorization |
| Bariatric Surgery (Certain restrictions and limitations may apply) | Yes |
| Durable Medical Equipment (DM) (Certain restrictions and limitations may apply) | Some items require prior authorization |
| Genetic Testing | Some items require prior authorization |
| Hearing Aids/Cochlear Inplants (Certain restricitons may apply) | Some items require prior authorization |
| High Cost Radiology | Yes |
| Home Health Care Services | Yes |
| Hospice Care | Yes |
| Hospital Services Inpatient | Yes |
| Hospital Services Outpatient | Some items require prior authorization |
| Laboratory Services: All services necessary for the diagnosis, treatment and prevention of disease, and for the maintenance of health. | Some items require prior authorization |
| Medical Services Clinic | Yes |
| Orthotics & Prosthetics (O&P): Braces (non-dental) and other mechanical or molded devices to support or correct any defect of form or function of the human body | Yes |
| Oxygen & Respiratory Services | Some items require prior authorization |
| Pain Management | Some items require prior authorization |
| Private Duty Nursing/Personal Care Services (Certain restrictions and limitations may apply)Some items require prior authorization | Yes |
| Sleep Studies | Yes |
| Therapy (OT, PT, ST) Services (Outpatient) (Certain restrictions and limitations may apply) | Yes |
| Transplant Services | Pre and Post Transplant services are covered by the health plan. Transplant is covered through MO HealthNet Fee-For-Service |
HSH23109 | 03/17/2023