Johns Hopkins Employer Health Programs (EHP) Outpatient Preauthorization Guidelines August 2021 | This list is NOT ALL INCLUSIVE
If you are unsure if the health care service or procedure your provider has ordered requires pre-authorization, please call Customer Service at 800-261-2393.
• EHP plan members have direct access to specialty providers in- or out-of-network (no referral required) • See back of Outpatient Referral and Preauthorization Guidelines for additional information specific to plan Overview • To verify benefit coverage call: 800-261-2393 • For additional information about EHP, refer to the website at: ehp.org
• Some medications that are administered by a provider, or under supervision of a provider, and processed through the member’s medical Provider-Administered Specialty Medications benefit may be subject to pre-authorization. Pre-authorization Required
No Notification Required/ • See back panel for specific coverage details No Preauthorization Required • Diabetes Education
Your provider must ask for and receive approval before you receive certain care. Johns Hopkins EHP will review the service, drug or Preauthorization Required equipment for medical necessity. This section lists the services that require pre-authorization.
• Ambulance, non-emergent • Hospice • Prenatal Obstetrical Ultrasound • Speech Therapy • Back Pain invasive procedures (facet • Hyperbaric Oxygen Therapy (beyond 3 and all 3D ultrasounds) • TMJ Treatment blocks, radiofrequency ablation) • Implanted Devices for Hearing Loss • Prosthetics • Transplants (except corneal) • Bariatric Surgery • Laser Treatment for Skin Conditions • Proton Beam Radiotherapy • Treatment of Acne and Actinic Keratosis • Biofeedback (see grid on back) • Light Box Therapy • Pulmonary Rehabilitation • Wig • Breast Reduction Male/Female • Long-Term External Cardiac Event • Pulse Oximetry at Home • Wound Clinic > 10 Visits • Bronchial Thermoplasty Monitoring (Zio Patch) • PUVA - Phototherapy • Wound Vac • Capsule Endoscopy • Minimally Invasive Treatments of • Radiology • Cardiac Rehabilitation Varicosities - Breast MRI • Clinical Trials (including NCI trials) • Neuropsychological Testing - Calcium Scoring (Electron Beam • DME/DMS • Neurostimulators Computed Tomography) • Elastography • Nutritional Counseling (see grid on back) - Heart CT/Angiography • Electroretinography • Occupational Therapy (see grid on back) - PET - Positron Emission Tomography • Extracorporeal Shockwave Therapy for • Orthotics • Reconstructive Surgery Plantar Fasciitis • Osteogenic Stimulation for Fractures - Alveolectomy/Alveoplasty • Feeding Programs • Palliative Care - Blepharoplasty, Brow Ptosis, Entropion, Ectropion • Gender Affirmation Treatment and • Pharmacogenomics Genotyping - Panniculectomy Procedures (see grid on back) • Physical Therapy (see grid on back) - Rhinoplasty/Septoplasty • Genetic Testing • Plastic Surgery (cosmetic procedures - Uvulectomy, Palatopharyngoplasty, • GERD Devices not covered) LAUP (Laser Assisted Uvuloplasty) • Home Health Care • Sclerotherapy
Behavioral Health • Providers call: 410-424-4845 or 800-261-2429 • Members call: 888-281-3186 or 410-424-4830 option 1 (Preauthorization Required) For services that require preauthorization, the health plan will perform medical review before they are rendered.
• Ambulatory Detox • ECT – Electro Convulsive Therapy - Intensive Outpatient Treatment (IOP) • Psychological Testing • Applied Behavioral Analysis • Psychiatric Care - Partial Hospitalization Programs (PHP) • TMS - Transcranial Magnetic Stimulation
Commonly Requested Non-Covered Services This section lists the commonly requested non-covered services that are not part of the EHP benefit.
• Autopsy - Grab Bars - Whirlpools/Whirlpool Bath • Podiatry - Routine Foot Care • Cosmetic Procedures - Heating Pads or Lamps Equipment (Except PVD/DM Diagnosis Only) • Cryopreservation (reproductive) - Home Health Aides • Interferential Therapy • Sterilization Reversal • Diabetic Shoes - Hot Water Bottles • LASIK Eye Surgery • Surrogacy • DME/DMS - Ice Bags • Learning Disabilities (refer to school system) • Ultrasound/CT Scan for Bone Density - Bed Boards - Structural Modification to the Home • Massage Therapy • Vitamin and Mineral Supplements - Diapers (including pull-ups and - Tray Tables • Naturopathic Treatment • Weight Management Programs Depends) - Wheelchair Tray Table • Nutritional Supplements - Exercise Equipment and Devices
Non-Covered Investigational Services This section lists the non-covered investigational services that are not part of the EHP benefit.
• Breast Ductal Lavage • Investigational Health Services/Equipment • Pulse Electrical Stimulation for OA of the • IDET - Intradiscal Electrothermal Therapy (not FDA approved) Knee
Resources This section lists the resources that may be helpful in meeting the needs of the EHP member and verify benefit limitations.
EHP Utilization Management EHP Website Behavioral Health Services Caremark Customer Service Call: 410-424-4480 or 800-261-2421 www.ehp.org Call: 888-281-3186 or 410-424-4830 Call: 800-552-8159 FAX: 410-424-4890 option 1 EHP Pharmacy Review Call: 888-819-1043 or 410-424-4490 Caremark Website EHP Customer Service www.caremark.com Call: 800-261-2393 option 4 Fax: 410-424-4607 Johns Hopkins Employer Health Programs (EHP) Plan Specific Benefits August 2021
EPO/PPO Johns Hopkins Hospital/ Health System Corporation EPO/PPO Howard County EPO/PPO Johns Hopkins Union Plan PPO Johns Hopkins University PPO Johns Hopkins University EPO/PPO Suburban Hospital Services & Supplies PPO Broadway Services, Inc. PPO Sibley Memorial Hospital E00008, E00009 General Hospital Bayview Medical Center E00091 Classic Plan Student Health Program E00085 Standard Plan E00006, E00007, E00161 E00015, E00051, E00151 E00016 E00070 E00080 Non-Union Plan E00090, E00092, E00093, E00190, E00192, E000194, E000198
No Preauthorization No Preauthorization No Preauthorization No Preauthorization No Preauthorization No Preauthorization No Preauthorization Preauthorization Required Abortion – Elective Required Required Required Required Required Required Required
No Preauthorization No Preauthorization No Preauthorization No Preauthorization No Preauthorization No Preauthorization Preauthorization Required Preauthorization Required Acupuncture Required Required Required Required Required Required
Bariatric Surgery No Benefit Preauthorization Required Preauthorization Required Preauthorization Required Preauthorization Required Preauthorization Required Preauthorization Required Preauthorization Required
Biofeedback No Benefit Preauthorization Required Preauthorization Required Preauthorization Required Preauthorization Required No Benefit Preauthorization Required Preauthorization Required
No Preauthorization No Preauthorization No Preauthorization No Preauthorization No Preauthorization No Preauthorization No Preauthorization No Preauthorization Chiropractic Care Required Required Required Required Required Required Required Required
Contraceptive Devices, IUD No Preauthorization No Preauthorization No Preauthorization No Preauthorization No Preauthorization No Preauthorization No Preauthorization No Benefit and Diaphragms Required Required Required Required Required Required Required
Gender Affirmation No Benefit Preauthorization Required Preauthorization Required Preauthorization Required Preauthorization Required Preauthorization Required Preauthorization Required Preauthorization Required Treatment and Procedures
For dependent children For dependent children For dependent children For dependent children For dependent children For dependent children Habilitative Services No Benefit up to age 19 up to age 19 up to age 19 up to age 19 Preauthorization Required up to age 19 up to age 19 Preauthorization Required Preauthorization Required Preauthorization Required Preauthorization Required Preauthorization Required Preauthorization Required
For dependent children For dependent children For dependent children For dependent children For dependent children For dependent children Hearing Aids No Benefit up to age 26 up to age 26 up to age 26 up to age 26 Preauthorization Required up to age 26 up to age 26 Preauthorization Required Preauthorization Required Preauthorization Required Preauthorization Required Preauthorization Required Preauthorization Required
Hypnosis No Benefit No Benefit No Benefit No Benefit No Benefit No Benefit No Benefit No Benefit
Infertility Treatment No Benefit Preauthorization Required Preauthorization Required Preauthorization Required Preauthorization Required Preauthorization Required Preauthorization Required Preauthorization Required
Notification to the Health Plan can be made by any servicing provider. Contact EHP Customer Service at: 800-261-2393 for plan specific limitations. You may also view the Plan’s Schedule of Benefits www.ehp.orgon .