Medical Policy and prior authorization requirements
Many insurance carriers require prior authorization for certain medical services, imaging (MRI, CT scans, etc.), procedures (surgery, injections, etc.), and prescriptions. This change is in response to updated guidelines issued by many insurance carriers and is aimed at ensuring medical necessity and coverage under your plan.
What Patients Should Know
Before receiving certain services, procedures, or prescriptions, OFC may need to request and obtain prior approval from your insurance carrier.
Prior to approval, your insurance carrier may require additional imaging, testing, and conservative treatment (NSAIDS, physical/occupational therapy, nicotine testing, etc.) to meet medical necessity.
Please allow additional time for the prior authorization process. OFC strives to process requests immediately, but insurance carriers may take several business days to review and approve.
It is important to keep your insurance information up to date and to notify OFC immediately of any changes.
Prior Authorization Requirements to Meet Medical Necessity
Office visit within the past year.
Imaging within the past year (x-ray, MRI, etc.).
Conservative treatment for 3-6 months:
Conservative treatment starts with the first time you are seen by a physician for that episode of pain.
Physical/Occupational therapy within the past 6 months to a year.
6 weeks treatment required for imaging.
3 months treatment required for surgeries.
Documented course of non-steroidal anti-inflammatory drugs (NSAIDs). Common NSAIDs include ibuprofen, aspirin, naproxen, etc.
BMI will dictate the length of conservative treatment required.
Nicotine free for 6 weeks (may require a nicotine test).
Documentation of pain relief from previous injections.
Additional testing to rule out other causes of pain.
If you have questions, please contact our Prior Authorization Department: 507-386-0002.