Prior Authorizations

Central Health Medical Management and Curative reviews prior authorization requests for MAP and MAP BASIC healthcare services not provided or arranged by Seton.

Seton Health Plan reviews prior authorization requests for the MAP and MAP BASIC healthcare services related to Seton provided or arranged healthcare services.  MAP BASIC healthcare services are provided pursuant to Seton Charity Care policies.

Prior authorization is used to assess the medical necessity of prescribed services. The majority of services do not require authorization.

Service Line Authorizations by Organization

• Central Health Medical Management: Authorizes certain Skilled Nursing Facility admissions as provided by CCC or Central Health.
• Curative: Authorizes customized durable equipment (ex. wheelchairs, toe fillers, hand and wrist braces, and orthotics and prosthetics) and additional Physical Therapy services beyond standard limit (10 visits).
• Seton Health Plan: For a listing of service/CPT codes that are managed by Seton Health Plan (SHP) please review the MAP Prior Authorization Grid posted on SHP’s website: https://www.seton.net/health-plan/providers/reference-center/
• Note: Information regarding Non-Formulary Drug Request authorizations can be found here: http://centralhealth.net/medical-access-program-provider/non-formulary-medication-request/

Prior Authorization Submission Process

• Central Health Case Management:
  • Complete the Case Management referral form
  • Submit the completed referral form to:
    • Fax: 512-978-8151
    • Online
  • Curative
    • Complete the Prior Authorization form
    • Fax completed authorization form and supporting documentation to 512-406-6244 or 866-272-2542 (toll-free)
  • Seton Health Plan:
    • Complete the Prior Authorization (including Polysomnography Sleep Study and Varicose Vein Referrals) form: Visit https://www.seton.net/health-plan/providers/reference-center/ for the latest version.
    • Fax completed authorization form and supporting documentation to 512-380-4253
  • Once received, the request is reviewed and authorized (approved) or denied. If approved, an authorization number is issued. A determination notice will be provided to the requestor.
    • Note: Reviewing organizations may request additional information or details to understand the nature of the request.
  • Authorization denials by Central Health or Curative can be appealed for reconsideration; appeals should be resubmitted to the organization that originally denied the service. Providers are encouraged to submit additional documentation justifying the requested service(s). An appeal determination communication will be provided to the requestor.
  • The Seton Health Plan has available peer to peer for adverse determinations. The attending provider may contact the SHP medical director that made the initial determination to discuss the services under review. The attending provider is notified within three (3) business days of the reconsideration decision.