The BWC’s MCO standardized prior authorization table
| Service | Prior Authorization Required | No Prior Authorization Required |
| Physical medicine services, including chiropractic/osteopathic manipulative treatment and acupuncture | Yes | |
| Psychological services | Yes | |
| Dental | Yes | |
| Evaluation and management services | Yes for psychological consults or chronic pain program consults | All other evaluation and management services |
| Diagnostic testing | Yes. For drug test, please refer to the “Drug Testing” policy. | Basic X-rays |
| Durable Medical Equipment (DME) | Yes, if purchase price is equal or greater than $250
Yes, for DME rentals anticipated to or having the probability to exceed 80 percent of the purchase price of the DME For DME, please refer to the “Durable Medical Equipment” policy. |
DME purchase price is less than $250 |
| Home/Vehicle modifications | Yes. For home/vehicle modifications, please refer to the “Home and Vehicle Modifications” policy. | |
| Home health agency services | Yes | |
| All inpatient and outpatient hospital services treatment and ambulatory surgery center services | Yes, unless for emergency services. Emergency inpatient hospitalization may be through the emergency department or by direct admission | |
| In-home physician services | Yes, after first visit
For in-home physician services, please refer to the “In-home Physician Visits and Physician Mobile Office Visits” policy. |
First visit |
| Injections | Yes | |
| Non-emergency ambulance (medical transportation) services | Yes | |
| Orthotic | Yes, if greater than $250 | |
| Prosthetic or artificial appliance and/or repair | Yes, if greater than $250
For prosthetic or artificial appliance and/or repair, please refer to the “Artificial Appliance Requests” policy. |
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| Skilled nursing facility (SNF)/Extended care facility (ECF) | Yes | |
| TENS and NMES units | Yes, for both rental and purchase
For TENS and NMES units, please refer to the “TENS and NMES” policy. |
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| TENS and NMES monthly supplies | Yes, with a maximum of six months per authorization
For TENS and NMES units, please refer to the “TENS and NMES” policy. |
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| Vision and hearing services | Yes, if greater than $100 | Vision and hearing services less than or equal to $100 |
| Vocational rehabilitation – all vocational rehabilitation services, in or out of plan | Yes, unless meets the “NoPA Required” criteria
For vocational rehabilitation, please refer to the vocational rehabilitation policies (click here). |
Transitional work on-site therapy services provided by an occupational therapist that fall under the presumptive authorization criteria
Note: Occupational rehabilitation/Comprehensive (work hardening) requires CARF |
This means the requesting physician will need to submit a C9 requesting the listed treatments before payment of those treatments will be considered.
For questions or concerns, please contact our office at 614-545-9990.