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Prior Authorizations and Referrals

Peach State Health Plan provides the same benefits as Medicaid and PeachCare for Kids®, plus more. In this section, you can learn about the health benefits, pharmacy services and value added services Peach State Health Plan offers.

Need help understanding these benefits and services? Call us at 1-800-704-1484 (TTY/TDD 1-800-255-0056).     

You can also view more information about Peach State Health Plan in our Member Handbook.

All services must be medically necessary. Your Primary Care Provider will work with you to make sure you get the services you need. These services must be given by your Primary Care Provider or by another provider that your Primary Care Provider refers you to. 

Some services may:

  • Have coverage limits.
  • Need a doctor’s order.
  • Need prior approval.

*Some Medicaid and PeachCare for Kids® members may not have all the benefits listed.

PRIOR AUTHORIZATION 

Peach State Health Plan must approve some treatments and services before our members can receive the service. The provider performing the treatment or service will submit a request for authorization to the health plan along with medical information that supports the treatment. Peach State Health Plan licensed and trained staff members review all prior authorizations and pre-certifications.

Be sure to receive the services listed below from a Peach State Health Plan provider. Services from a provider who is not in the Peach State Health Plan network must be approved ahead of time. This does not apply to emergency services or family planning services.

Some covered services or medications may need approval from Peach State Health Plan, and this is called a Prior Authorization. You do not need a paper referral from Peach State Health Plan to see a provider, but your provider may need to request a prior authorization from Peach State Health Plan for a service to be approved.

Below is a list of services that require prior authorization from Peach State Health Plan before your healthcare provider can proceed with treatment.

  • Nursing facility services.
  • Home healthcare.
  • Hospice care (care for terminally ill). For example, cancer patients.
  • Inpatient hospitalization.
  • In-patient hospital services. Hospital care is arranged by your primary care provider (PCP) except in the case of an emergency. In-patient hospital care is provided at one of the hospitals associated with Peach State Health Plan. These hospitals are listed in your Provider Directory.
  • Partial hospitalization.
  • Residential Care for behavioral health.
  • Medical supplies. Some diabetic supplies for insulin and blood glucose monitoring do not require authorization.
  • Durable Medical Equipment.
  • Speech and hearing services. Including hearing aids.
  • Physical and occupational therapy.
  • Non-routine dental care. For example, surgery.
  • Non-routine vision (optical) services. For example, surgery.
  • Non-emergency ambulance transportation.
  • Plastic and re-constructive surgery.
  • Certain diagnostics tests. For example. MRI/MRA, PET scans.
  • Sleep Studies. (Exception: No Prior Approval required when Sleep Study is performed in the home)
  • Transplant procedures and related services, regardless of age.
  • Chemotherapy.
  • Radiation cancer treatment.

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