Outpatient Prior Authorization

Understanding Criteria and Coverage

Outpatient prior authorization exists to make sure that coverage is available and that the most appropriate treatment is used for certain outpatient services and injectable drugs.

Certain outpatient services must be prior authorized utilizing criteria developed and approved by the Medical Advisory Council. You can learn more about the criteria for Medical and Surgical prior authorizations by clicking on one of the links below. You may also contact the Utilization Management Department at 419-887-2520 or toll free at 800-891-2520 if you have any questions.

Prior Authorization – Experimental/Investigational - Noncovered Services List

Imaging Authorization Fax Worksheet

Paramount uses the following clinical criteria to ensure appropriateness of care and service:

• Centers for Medicare & Medicaid Service (CMS) for national coverage determinations. CGS Administrators, LLC., Jurisdiction A/B, and Wisconsin Physicians Service Insurance Corporation for local coverage determinations.
  
  • CMS Medical Benefit Policy Manual
  • CMS Medicare Coverage Database (MCD)
  • CGS Administrators, LLC., Jurisdiction A/B
• InterQual Coverage Criteria
• Other Paramount Healthcare approved medical policies
• In cases of a discrepancy between InterQual and Paramount Medical policies, InterQual will supersede Medical Policy language.