Utilization Management
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Information about prior authorizations.

Utilization Management reviews prospective, concurrent and retrospective services to determine medical necessity, appropriateness, and reasonableness for our members. Our goal is to ensure quality services and patient outcomes in a cost efficient manner. Our nurses are locally based and have a robust knowledge of the community and the healthcare services available and are here to help you with your healthcare needs. Below is a list of items that commonly require authorization.

Prior Authorization Requirements

Pre certification may be required for the following. Please contact Medical Associates Health Plans at 1-866-821-1365 or 563-584-4885 for plan specific requirements:

  • All DME over $500
  • All Inpatient Admissions including Rehab and Long Term Acute Care
  • All Same Day Surgeries requiring an overnight stay
  • Apnea Monitors
  • Bariatric Surgery
  • Blepharoplasty
  • Chemotherapy
  • Clinical Trials
  • Cochlear Implants
  • CPM Machines
  • Dental or oral surgical services
  • Diabetic Shoes
  • Enteral or parenteral feeding
  • Gender Reassignment
  • Genetic Testing
  • High cost radiology tests (CT/CTA, HIDA Scan, MRI/MRA, PET Scan, Ultrasound)
  • Home Health (nursing, therapy, home infusions, etc.)
  • Hospice
  • Hyperbaric Oxygen Treatment
  • Hysterectomy (Vaginal or Abdominal)
  • Implantable Bone Conduction Hearing Device
  • Insulin pumps and supplies (initial request and every 3 months after approval)
  • Joint Replacement
  • Neuroablation
  • Nutritional Counseling, including Diabetic Education
  • Outpatient Therapies, i.e. physical therapy, speech therapy and occupational therapy
  • Panniculectomy
  • PT/INR Home Monitoring Device
  • Pulse Oximeters
  • Reconstructive Surgery, including those resulting from accident or disease
  • Radiation Oncology
  • Reduction Mastectomy
  • Residential Care Facility
  • Rhinoplasty
  • Seat Lift Mechanisms
  • Skilled
  • Sleep Studies
  • Transcranial Magnetic Stimulation
  • Varicose Vein Treatment (Sclerotherapy, Stripping or Endovenous Ablation)
  • Wound Clinic
  • Wound VAC therapy

If you are a member and need help finding the appropriate provider, determining if your medical care needs authorization, or regarding another health care concern, you can contact Health Care Services at 563-584-4885 or toll free 1-866-821-1365.

If you are a provider, you may call Health Care Services at 563-584-4885 or toll free 866-821-1365 to inquire about the authorization process or to help navigate a member’s healthcare needs. Medical Associates Health Plans and Health Choices utilizes My eLink, a portal to submit electronic requests, for authorizations.  If you are not able to utilize My eLink, you may fill out and send in the prior authorizations forms.