Prior Authorization

When you need health care, always start with a call to your medical or behavioral health (mental health or substance use disorder) provider. Some covered services or medications may need approval from CeltiCare Health before you receive the service. This is called a Prior Authorization. You do not need a paper referral from CeltiCare Health to see a provider but your provider may need to request a prior authorization from CeltiCare Health for a service to be approved. Below is a list of services that require prior authorization from CeltiCare Health before your healthcare provider can proceed with treatment.

Inpatient Hospitalization

Pre-scheduled, non-emergent services must be approved by CeltiCare Health before you are admitted. Your provider will send a request to CeltiCare Health.

How do I ask for a second opinion?

You have the right to a second opinion from a CeltiCare Health provider if you are not satisfied with the plan of care offered by the specialist. Your primary care healthcare provider should be able to give you the name of a provider for a second opinion visit. If your primary care provider wants you to see a specialist that is not a CeltiCare Health provider; that visit will have to be approved in advance by CeltiCare Health.

Non-Participating/Out-of-Network Providers

Requests for services from a provider, facility, or vendor that is not in the CeltiCare Health network need to be approved by getting a prior authorization.

Your healthcare provider can tell you if a healthcare service or prescription needs prior authorization. The list below gives you general categories of services requiring Prior Authorization. Please keep in mind that services and benefits change from time to time. This prior authorization list is for your general information only. Please call CeltiCare Health Member Services for the most up to date information at 1-855-678-6975 (TDD/TTY: 1-866-614-1949), Monday – Friday, 8:00 a.m. – 5:00 p.m.

MassHealth CarePlus Services that require a Prior Authorization for CeltiCare Health Members

The services listed below are the covered services that require prior approval from CeltiCare Health.  For a listing of all covered services please refer to the Covered Services List.

Service Name Prior Authorization Required?
Medical Services  
Abortion Services Yes
Acute Inpatient Hospital Services:  Includes all inpatient services such as daily physician intervention, surgery, obstetrics, radiology, laboratory and other diagnostic and treatment procedure and shall include the medically necessary days. Yes
Ambulatory Surgery Services:  Includes outpatient surgical, related diagnostic and medical and dental services. Yes
Dental Services: Includes Oral surgery performed in an outpatient hospital or ambulatory surgery setting which is medically necessary to treat an underlying medical condition. Yes
Dental Services:  Preventive and basic services for the prevention and control of dental diseases and the maintenance of oral health for adults.

CeltiCare Health will help coordinate this service for you. Please call us at 1-855-678-6975 (TDD/TTY: 1-866-614-1949)

Durable Medical Equipment: Includes but is not limited to the purchase or rental of medical equipment, replacement parts, and repair for such items.

Yes

Hearing Aid Services

Yes

Home Health Services

Yes

Hospice Services [1]

Yes

Infertility: Includes the diagnosis of infertility and treatment of underlying medical condition.

Yes

Laboratory Services: All services necessary for the diagnosis, treatment and prevention of disease, and for the maintenance of health.

Yes

Orthotic Services: Braces (non-dental) and other mechanical or molded devices to support or correct any defect of form or function of the human body.

Yes

Outpatient Hospital Services: Services provided at an outpatient hospital, for example:

  • outpatient surgical and related diagnostic, medical and dental services
  • office visits for primary care and specialists
  • OB/GYN and prenatal care* therapy services (physical, occupational and speech)
  • diabetes self-management training
  • medical nutritional therapy
  • tobacco cessation services

If you are pregnant, you should contact MassHealth or CeltiCare Health because you will qualify for additional benefits due to your pregnancy.

Yes

Oxygen & Respiratory Therapy Equipment

Yes

Prosthetic Services

Yes

Radiology and Diagnostic Services

For Example:

  • X-Rays
  • magnetic resonance imagery (MRI) and other imaging studies
  • radiation oncology services performed at radiation oncology centers (ROCs) which are independent of an acute outpatient hospital or physician service.

Yes

Skilled Nursing Facility, Chronic Disease and Rehabilitation Hospital Services [2]

Yes

Therapy Services

For example:

  • occupational therapy
  • physical therapy
  • speech/language therapy

Yes

Transportation Services (Non-Emergency):  Non-emergency transportation by land ambulance, chair car, taxi, and common carriers that generally are pre-arranged to transport an Enrollee to and from covered medical care in Massachusetts or within 50 miles or less of the Massachusetts border. CeltiCare Health will help coordinate this service for you. Please call us at 1-855-678-6975 (TDD/TTY: 1-866-614-1949)
Transportation Services (Non-Emergency):  Non-emergent to out-of-state location – ambulance and other common carriers that generally are pre-arranged to transport an Enrollee to a service that is located outside a 50-mile radius of the Massachusetts border

Yes

Vision Care: vision training, ocular prosthesis; contacts, when medically necessary, as a medical treatment for a medical condition such as keratoconus; and bandage lenses.

Yes

Vision Care: Prescription and dispensing of ophthalmic materials, including eye glasses and other visual aids, excluding contacts.

CeltiCare Health will coordinate this service for you. Please call us at 1-855-678-6975 (TDD/TTY: 1-866-614-1949)

Wigs: as prescribed by a physician related to a medical condition

Yes

Pharmacy Services (Medications):

 

  • Prescription Medicines
  • Over- the- Counter Medicines

Yes

Behavioral Health (Mental Health and Substance Use Disorder) Services

 

Non-24 Hour Diversionary Services:

  • community support programs
  • partial hospitalization
  • structured outpatient addiction program (SOAP)
  • intensive outpatient program (IOP)
  • psychiatric day treatment

Yes

24 Hour Diversionary Services:

  • crisis stabilization unit
  • acute treatment services for substance abuse (Level III.7)
  • clinical support services – substance abuse (Level III.5)

Yes

Inpatient Services:

  • Inpatient mental health services
  • Inpatient substance abuse services (Level IV)

Yes

Yes

Outpatient Services, such as:

  • individual, group, and family counseling
  • medication visits
  • family and case consultations
  • diagnostic evaluations
  • psychological testing narcotic-treatment services (including acupuncture)
  • electro-convulsive therapy

 

Yes

Some of these services require Prior Authorization

[1] A CeltiCare Health CarePlus member can get hospice care from CeltiCare Health or MassHealth.  If you choose to receive hospice care from MassHealth you will be disenrolled from CeltiCare Health CarePlus and receive all of your health care services from MassHealth.

[2]  CeltiCare Health covers up to 100 days of a combination of Skilled Nursing, Chronic Disease and Rehabilitation Hospital Services in a Contract Year. If you need Chronic Disease and Rehabilitation Hospital Services beyond the 100 days provided by your health plan, you will be disenrolled from  CeltiCare Health CarePlus and  receive such services from MassHealth on a fee-for-service basis. If you need Skilled Nursing Facility Services beyond the 100 days provided by your health plan, you may qualify for MassHealth Standard. Call MassHealth Customer Service to see if you qualify; if you do, you will be disenrolled from CeltiCare Health CarePlus and will receive such services form MassHealth instead of CeltiCare Health. Call CeltiCare Health CarePlus or MassHealth Customer Service for more information.

All such services determined by CeltiCare Health CarePlus to be medically necessary shall constitute a CeltiCare Health CarePlus Covered Service.  See the CeltiCare Health CarePlus Member Handbook and Covered Services List for more information on coverage out-of-network and out of the CeltiCare Health service area.