Authorizations/Precertifications for FEHB and PSHB HDHP, Standard and High health members
Important note: The authorization information on this page is for G.E.H.A's FEHB/PSHB HDHP, Standard, and High health plan members. For other health plans, visit Authorizations/Precertifications for FEHB/PSHB Elevate and Elevate Plus health members.
For Providers – To submit an authorization or for more information and help with authorizations, please access the Provider portal
For Members – For more information and help with authorizations, please access the MyGEHA member portal
General information
- Authorization requirement: G.E.H.A, 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 G.E.H.A plan brochure. For quick reference, see the G.E.H.A 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 G.E.H.A 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 G.E.H.A coverage when traveling, click Outside the United States.
Contact information
- Benefits and eligibility: Call G.E.H.A's Customer Care department at 1-877-460-7673.
- Prior authorization: Refer to the back of the patient's ID card for the appropriate contact information and submission.
Benefits 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:
- Cancer treatment
- Fertility procedures and medications
- Prescription drugs
- Specialty prescription drugs
| Benefits requiring authorization | |
|---|---|
| Category | Procedures |
| Applied Behavioral Analysis (ABA) therapy | Applied Behavioral Analysis (ABA) therapy |
| Arthroplasty | Including revisions to a prior arthroplasty |
| Back and spinal procedures | Discectomy/fusion, intrathecal pump insertion for pain management (morphine pump, baclofen pump), neurostimulation-spinal |
| Bariatric surgery | Bariatric and metabolic surgical procedures (obesity surgery) |
| Behavioral health facilities and programs (includes mental health and substance use disorders) | Acute inpatient, Sub-acute inpatient, Residential Treatment Centers (RTC), Intensive Outpatient Programs (IOP), Partial Hospitalization Programs (PHP) |
| 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 |
| Hysterectomy | Except for diagnosis of cancer |
| Medical/Surgical facilities | Acute inpatient, Long-Term Acute Care (LTAC), Acute Rehabilitation Facility (ARF), Skilled Nursing Facility (SNF) |
| Neurostimulation | Neurostimulation, including devices and implantation procedures for cranial, gastric, peripheral, spinal or vagus nerve stimulation |
| Non-emergency air ambulance | Non-emergency air ambulance transportation |
| Orthognathic surgery | Jaw surgery, including TMJ |
| Orthopedic devices | Orthopedic devices and prosthetic devices |
| Prostate implants, destruction and removal | Prostate implants, destruction and removal |
| Psychological and neuropsychological testing | Exceeding 8 hours/year |
| Radiology (high tech outpatient radiology/imaging) | • CT — Computerized Axial Tomography • LDCT — Low-dose computed tomography • MRI — Magnetic resonance imaging • MRA — Magnetic resonance angiography • NC — Nuclear cardiac imaging studies • PET — Positron emission tomography |
| 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 |
| Transplants | Organ and tissue transplant procedures |
| Wound care (outpatient) | Advanced wound therapy |
Specific instructions for authorization on the following services:
| Cancer treatment — non-surgical outpatient cancer treatment including chemotherapy, radiation, and cell and gene therapy |
|
| Fertility procedures and medications |
|
| Prescription drugs |
|
| Specialty prescription drugs |
|