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Your certificate of coverage is a helpful resource for covered services under your benefit plan. There are some situations where you might need to obtain a referral from your Primary Care Doctor or from Total Health Care’s (THC) utilization management department. In most cases, your doctor will contact THC to request an authorization for you, when needed.

Referrals:

Effective with dates of service April 1, 2021, referrals are required for high-tech radiology services, such as a CT Scan, MRI or PET Scan, as well as nuclear cardiology services. You can see the list of services that require a referral by clicking here.

Authorizations:

Obtaining an authorization from THC requires your doctor to send medical documentation to THC’s utilization management department for review. Once the medical documentation is received by your doctor, our utilization management nurses and doctors will use criteria to make sure that the request is medically necessary and covered by your benefit plan. For non-urgent requests, THC’s utilization management department will provide a response in less than 14 calendar days. For urgent medical requests (where the member’s health could be seriously affected by waiting 14 days), THC’s utilization management department will respond within 3 calendar days.

Examples of services that may require authorization from THC’s utilization management department include elective (non-emergency) inpatient surgeries, medical devices and pumps, and out of network services. Services that are covered under your benefit plan will be listed in your certificate of coverage. You may also see a list of services that requires authorization from THC by clicking here.

It is important to obtain authorization for these types of services before making plans or taking time off from work.

Prior Authorization From THC

PCP must FAX clinical information to THC Utilization Department at 313-748-1312

Abortion – (Medicaid only)

Admissions:

  • Inpatient Hospital – acute, emergent, elective
  • Long Term Acute Care Admission
  • Skilled Nursing Facility
  • Acute & Sub-Acute Rehabilitation
  • Excluding Observation Stay (no auth required)

Surgeries:

  • Abdominoplasty / Panneculectomy
  • Bariatric (excluding lap band adjustments)
  • Blepharoplasty
  • Breast Reduction / Augmentation
  • Bunionectomy
  • Cosmetic Surgeries not otherwise listed
  • Foot – all
  • Hammertoe
  • Hysterectomy (need form only)
  • Transplant, Organ, Tissue, Bone Marrow
  • Rhinoplasty / Septoplasty
  • Scar Revision / Keloid Removal
  • Surgery to Treat Varicose Veins

Device Implants- including, not limited to:

  • Insulin pumps, continuous glucose monitors
  • Interstim therapy
  • Penile Implant
  • Vagus nerve/bone growth stimulators
  • Implantable Loop Records (cardiac)

Anti-emetic Drugs

Genetic Testing

Home Health Care / Hospice

Infusion Therapy

Laser Treatment for Skin Diseases

Specialty Medication Injections (see separate list)

Out of Network Services(excludes Select POS)

Prosthetics/Orthotics- > $200

Sterilization-Male/Female

Temporomandibular Joint (TMJ) Procedures

PT/OT/ST Treatment (excludes Select POS)

Behavioral Health

Substance Abuse Services

Power/motorized wheel chairs

Experimental & Investigational Services

Non-emergent ambulance transportation

Cardiac LifeVest

Apheresis

Contact Lenses, Prosthetic Eyes, Low Vision Aids

PCP Initiated Referral (Excludes Select POS)

Must process through the Provider Portal
Services must be provided in network

High-tech radiology exams:

  • CT Scans
  • MRIs, MRAs
  • PET Scans
  • Nuclear Studies
    • Cardiac Stress Test
    • MUGA
    • HIDA Scan