American health holding prior authorization phone number

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© Wisconsin Physicians Service Insurance Corporation and WPS Health Plan, Inc. EEO/AA employer. All rights reserved. Wisconsin Physicians Service®. The intent of this advertisement is solicitation of insurance, and contact may be made by the insurer or a licensed agent. Neither Wisconsin Physicians Service Insurance Corporation, nor its agents, nor products are connected with the federal Medicare program. Green Bay Packers and Milwaukee Brewers™ partnerships are paid endorsements.

Certification is a review process used to determine if services are medically necessary according to HealthChoice guidelines. Certification is also referred to as prior authorization, precertification or preauthorization. All HealthChoice plans require certification for coverage of specified services. Certification approval does not guarantee benefits. Clinical editing and other plan policies, provisions and criteria apply.

Guidelines

Certification reviews are performed by either the HealthChoice Health Care Management Unit (HCMU) or the HealthChoice Certification Administrator, currently American Health Holdings (AHH), depending on the type of service. To request certification, complete the online request form or contact the appropriate certification unit noted below for the service(s) being requested. Certification requests that are not accurately completed or that are submitted to the incorrect area could be delayed or not processed.

For non-urgent services, certification requests must be initiated within three working days prior to the scheduled service. For urgent services, certification must be initiated within one day following the service. Services rendered in an emergency department and/or ambulance are not subject to certification requirements. For more information on certification, appeal rights and more refer to the HealthChoice Provider Manual.

If certification approval is not obtained for services that require it and/or if certification is denied either before or after the services are provided, claims for those services will be denied. For certifications approved after services are provided, a 10% penalty deduction on the allowable amount is applicable. Network providers are not allowed to impose certification penalties on members or their covered dependents.

For a more detailed list of the service codes that require certification, please refer to the HealthChoice Certification Code List found on the HealthChoice Fee Schedule site or call HealthChoice Customer Care.

The below services require certification through the Healthchoice Health Care Management Unit (HCMU)

For a more detailed list of the codes that require certification, please refer to the       
HealthChoice Certification Code List found at https://gateway.sib.ok.gov/feeschedule/Login.aspx      
For more information or to request certification for these services, contact HCMU at
1-405-717-8879.  For TTY call 711.  Fax: 1-405-949-5459 or 1-405-949-5501.

1. Chiropractic Therapy
   a. Required only after initial 20 visits per calendar year.
   b. Visits are limited to 60 total per calendar year (some exceptions apply).
2. Drugs and Medical Injectable
   a. Required for specified medications covered under the HealthChoice medical plan; this is not inclusive of requirements under the HealthChoice Pharmacy Benefits Administrator.
   b. Required for Botox Injections that are non-cosmetic and rendered in the Physician’s Office.
3. Durable Medical Equipment
4. Enteral Feeding
5. Foot Orthotics
6. Genetic Testing
7. Glucose Monitors: Continuous
8. Hearing Aids
9. Home Health Care (Visits limited to 100 per calendar year)
10. Home Intravenous (IV) Therapy (not subject to Home Health Care limits)
11. Hyperbaric Oxygen Therapy (Outpatient)
12. Mental Health Treatment
    a. Required for Outpatient services after initial 20 visits per calendar year.
    b. Required initially for Intensive Outpatient Therapy services.
    c. Required initially for TMS treatment.
    d. Required initially for Applied Behavior Analysis services.
13. Occupational Therapy (Outpatient)
    a. Required after initial 20 visits per calendar year.
14. Oral Splints and Appliances (some exceptions apply)
15. Oral Surgery (Inpatient/Outpatient)
16. Oxygen
17. Physical Medicine/Physical Therapy (Outpatient)
    a. Required only after initial 20 visits per calendar year.
    b. Visits are limited to 60 total per calendar year (some exceptions apply).
18. Prostheses and Orthopedic Appliances (some exceptions apply)
19. Speech Therapy
    a. Required only for age seventeen (17) years or younger.
    b. Visits are limited to 60 total per calendar year (some exceptions apply).
20. Substance Abuse Disorder Treatment
    a. Required for Outpatient services after initial 20 visits per calendar year.
    b. Required initially for intensive Outpatient Therapy services.
21. Unlisted and Not Otherwise Specified - required for specified codes

The below services require certification through the HealthChoice Certification Administrator (AHH).

For a more detailed list of the codes that require certification, please refer to the 
HealthChoice Certification Code List found at https://gateway.sib.ok.gov/feeschedule/Login.aspx
For more information or to request certification for these services, contact AHH toll-free at 1-800-323-4314, option 2.  For TDD call toll free at 800-5458279.  Fax: 1-855-532-6780

1. Bariatric Surgery (Eligibility criteria also required)
2. Exhaustion of Medicare Lifetime Reserve Days
   a. Required for the additional 365 lifetime reserve days for hospitalization.
3. HealthChoice is 2nd or 3rd Payer
   a. Required only after Medicare benefits are exhausted.
4. Inpatient Admissions
5. Maternity Care
   a. Required if patient and baby are not discharged within 48 hours of vaginal delivery or within 96 hours of C-section delivery.
6. Mental Health Treatment (Inpatient, Residential, Partial Hospital)
7. Myocardial PET Scan
8. Observation Stays =/> 48 hours
9. Outpatient Surgical Procedures:
   a. Blepharoplasty
   b. Mammoplasty (including reduction, removal of implants and symmetry)
   c. Correction of Lid Retraction
   d. Panniculectomy
   e. Rhinoplasty
   f. Septoplasty
   g. Varicose vein surgeries and procedures
        i. Including Sclerotherapy
   h. Sleep Apnea related surgeries, limited to:
        i. Radiofrequency Ablation (Coblation, Somnoplasty)
        ii. Uvulopalatopharyngoplasty (UPPP), including laser-assisted procedure
10. Prophylactic and Gynecomastia Mastectomies
11. Proton Beam Radiation Therapy
12. Skilled Nursing Facility
13. Spinal Surgical Procedures
    a. Cervical
    b. Lumbar
    c. Thoracic
14. Spinal Cord Stimulator Placement and Revision
15. Substance Use Disorder Treatment (Inpatient, Residential, Partial Hospital)
16. Transplants
17. Unlisted and Not Otherwise Specified - required for specified codes

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