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Authorizations/Precertifications HDHP, Standard and High Option members


Important note: The authorization information on this page is for GEHA's HDHP, Standard, and High plan members. For other medical plans, visit Authorizations/Precertifications for Elevate and Elevate Plus members.

General information

  • Authorization requirement: GEHA, like other federal health plans, requires providers to obtain authorization before some services and procedures are performed.
  • Reference: More information can be found in the GEHA plan brochure. For quick reference, see the GEHA member's ID card.
  • Clinical guidelines: The sources of our clinical guidelines can be found on our Sources of Utilization Management Criteria (PDF).
  • Primary payer: If Medicare or another group health insurance policy is the primary payer for these services, you do not need to obtain authorization.

Emergency admissions
If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function:

  • Action required: You, your representative, the doctor, or the hospital must call GEHA within two business days following the day of the emergency admission, even if you have been discharged from the hospital.
  • Responsibility: Although your physician or hospital will precertify your stay, it is your responsibility to ensure that precertification is complete.
  • Failure to precertify: Failure to precertify inpatient stays could result in a benefits reduction.
  • International admissions: It is not necessary to precertify hospital admissions outside the United States. For more details on your GEHA coverage when traveling, click Outside the United States.

Contact information

  • Benefits and eligibility: Call GEHA's Customer Care department at 1-800-821-6136.
  • Prior authorization: Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission.

Services/Surgeries requiring authorization

Authorization is required for all services addressed below.

Please scroll to the bottom of the page for details regarding obtaining prior authorization on the following services:

  • Applied Behavioral Analysis (ABA) therapy
  • Cancer treatment
  • Fertility procedures and medications
  • Prescription drugs
  • Specialty prescription drugs
  • Radiology
  • Transplants
Surgeries/Procedures Requiring Authorization
To obtain authorization on the following services, providers should contact UnitedHealthcare at 1-877-585-9643.
Category Procedures
Arthroplasty Including revisions to a prior arthroplasty
Back and spinal procedures Discectomy/fusion, implanted infusion pumps and insertion procedures for pain management, spinal cord stimulators
Bariatric surgery Bariatric and metabolic surgical procedures (obesity surgery)
Bone growth stimulators Bone growth stimulators
Breast and chest surgeries Breast reconstruction (non-cancer), gynecomastia treatment (cosmetic), mammoplasty reduction
Cardiac and vascular procedures Ablative treatment of venous insufficiency including sclerotherapy and microphlebectomy, implantable cardiac monitoring, nuclear medicine studies including nuclear cardiology, transcatheter arrhythmia ablation, transcatheter aortic and pulmonary valve repair or replacement
Cartilage implants Autologous Cultured Chondrocytes (ACI), osteochondral grafting
Cellular and gene therapy Cellular and gene therapy
Cochlear implants Cochlear and auditory implants and procedures
Durable medical equipment Durable medical equipment (DME)
Experimental/Investigational Surgery or treatment, including clinical trials
Genetic testing Genetic testing
Hyperhidrosis Surgical treatment (requires failure of alternative therapies)
Hysterectomy Except for diagnosis of cancer
Medical/Surgical facilities Acute inpatient, Long-Term Acute Care (LTAC), Acute Rehabilitation Facility (ARF), Skilled Nursing Facility (SNF)
Mental health facilities and programs Acute inpatient, Sub-acute inpatient, Residential Treatment Centers (RTC), Intensive Outpatient Programs (IOP), Partial Hospitalization Programs (PHP)
MR-guided Focused Ultrasound MR-guided Focused Ultrasound (MRgFUS)
Non-Emergency air ambulance Non-emergency air ambulance transportation
Orthognathic surgery Jaw surgery, including TMJ
Orthopedic devices Orthopedic devices and prosthetic devices
Psychological and neuropsychological testing Exceeding 8 hours/year
Reconstructive or potential cosmetic procedures Abdominoplasty, panniculectomy, lipectomy, eyelid surgery, brow lift, rhinoplasty, scar revisions, surgical correction of congenital anomalies
Sleep studies (in-lab) Attended or performed in a health care facility (home sleep studies do not require preauthorization)
Speech devices Speech-generating devices
Surgical treatment of airway obstructions, including for sleep apnea Uvulopalatopharyngoplasty (UPPP), hyoid myotomy and suspension, Functional Endoscopic Sinus Surgery (FESS), sinuplasty, correction of choanal atresia and intranasal synechia
Surgical treatment of gender dysphoria Surgical treatment of gender dysphoria
Wound care (outpatient) Advanced wound therapy
Specific instructions for authorization on the following services:
Applied Behavior Analysis (ABA) therapy
  • Contact: Providers should contact Optum at 1-855-583-3164 for authorization. Optum does not accept fax requests.
  • Assessment: Providers must complete an ABA assessment form for initial requests. The ABA assessment must be approved before the ABA treatment starts. Once the assessment is complete, the provider can call and complete the clinical review over the phone.
  • Review: The form is updated during concurrent review (usually every 6 months).
Cancer treatment
  • Contact: Providers should log in to oncohealth.us and select Provider Login dialog box and select GEHA. If you experience any issues using the oncohealth.us site or if you need access credentials for the portal, please contact OncoHealth Client Support at 1-888-916-2616.
  • Review: Non-surgical outpatient cancer treatment, including chemotherapy and radiation.
  • Approval: Immediate authorization for evidence-based treatment. Customized plans require special review. Please note, some treatments may have applicable GEHA coverage policies which can be found at GEHA's Provider Resource Center.
  • Please note: Based on the GEHA member's benefits, some medications must be obtained from CVS Caremark to avoid penalties to the member. For information about which drugs require specialty dispensing, please contact CVS Caremark at 1-855-240-0536.
Fertility procedures and medications
  • Contact: Providers should contact Progyny at 1-866-960-3951 or visit progyny.com.
  • Review:
    • Artificial insemination procedures (intravaginal insemination, intracervical insemination, intrauterine insemination)
    • Harvesting of sperm/eggs and storage of sperm/embryos/eggs for iatrogenic infertility diagnosis
    • Medications prescribed as part of fertility preservation and treatment of infertility
Prescription drugs
  • Contact: CVS Caremark at 1-855-240-0536 for specialty and certain prescription drugs; for growth hormone therapy, call GEHA at 1-800-821-6136
  • Review: Some medications must be approved before they are a covered benefit.
    • Certain prescription drugs
    • Certain specialty prescription drugs
    • Certain drugs to treat infertility
    • Botox injections
    • Injectable drugs for arthritis, psoriasis, or hepatitis
    • Injectable hematopoietic drugs (drugs for anemia, low white blood count);
    • Growth hormone therapy (GHT) — Call GEHA at 1-800-821-6136 for GHT preauthorization
  • Members must make sure that their physicians obtain the prior approval/authorization for certain prescription drugs and supplies before coverage applies. Medication may be limited as to its quantity, total doses, duration of therapy, age, gender, or specific diagnosis. Pre-approval/authorizations must be renewed periodically. See Prescription Drug Benefits in the GEHA Plan Brochure.
Specialty prescription drugs
  • Contact: Prior approval/authorization required. Contact CVS Caremark at 1-855-240-0536.
  • Review: Certain specialty prescription drugs to treat severe medical conditions and are usually administered by injection or infusion. See Specialty Drug Benefits in the GEHA Plan Brochure.
Radiology
  • Contact: Ask your provider to call eviCore at 1-866-879-8317 or visit evicore.com before scheduling the procedure. Services that are not preauthorized will require retrospective review for medical necessity.
  • Review: The following outpatient radiology/imaging services need to be preauthorized:
    • CT — Computerized Axial Tomography
    • MRI— Magnetic resonance imaging
    • MRA — Magnetic resonance angiography
    • NC — Nuclear cardiac imaging studies
    • PET — Positron emission tomography
Transplants
  • Contact: For authorization and help identifying facilities within GEHA's transplant network, call 1-800-821-6136, ext. 3009.
  • Review: Organ and tissue transplant procedures require authorization.
  • Note: Authorization is not required for cornea or kidney transplants, which are paid under GEHA's medical benefit. The transportation benefit is not available for cornea or kidney transplants.