Cement Masons and Plasterers Health and Welfare Fund Prior Authorization

The following table is only a general guideline to Cement Masons and Plasterers Health and Welfare Fund prior authorization requirements. This list may be updated from time to time. It is the provider’s responsibility to check for updates. If the procedure billed is not the procedure approved, there may be no payment and the patient might not be liable. Verification of benefits and eligibility should be obtained by calling Zenith Administrators at 702-415-2190.

Prior authorization rules by place of service

For Prior Authorization, please contact NEVADA HEALTH SOLUTIONS:
Phone: 702-216-1653
Toll Free: 855-487-0353
Fax: 866-201-5601
https://www.nevadahealthsolutions.org

Call Zenith Administrators at 702-415-2190 to verify benefits and eligibility.

Prior authorization is required for:

In Office or Freestanding Facility

Orthotic and prosthetic appliances Orthotic and prosthetic appliances that are over $500 require prior authorization.
Radiology services

Prior authorization required for CT/CTA, Discography, MRI/MRA, PET Scans.

No prior authorization required for diagnostic testing (doppler, ultrasound, venous ultrasound, DEXA scan, mammogram).

Cardiology services Prior authorization required for cardiac monitoring, myocardial perfusion imaging.
Laboratory genetic testing Prior authorization required. Only covers genetic testing required by ACA.
Septoplasty/Rhinoplasty Prior authorization required only if anesthesia is used.
EEG Monitoring (Continuous and Video) No prior authorization required for 95913, 95886, 95812, and 93886.

DME

DME
Rented or purchased 		Prior authorization required for durable medical equipment items that are over $500.

Freestanding treatment/​radiology facility

Dialysis Utilizes a dialysis program
Radiology services

Prior authorization required for CT/CTA, MRI/MRA, and PET Scans.

No prior authorization required for x-ray, or diagnostic testing (doppler, ultrasound, DEXA scan, mammogram).

Home health and home infusion services

All skilled services in a home setting Prior authorization required.

Ambulatory surgery center

All procedures Prior authorization required.

Outpatient hospital
No out-of-network for EPO

All procedures Prior authorization required for any procedure which requires anesthesia.

Inpatient hospital

Observation Prior authorization required.
Inpatient emergent/​elective Prior authorization required.
Maternity

No prior authorization required for 2 days vaginal/4 days C-section (48/76 hour rule)

*Dependent child not covered for pregnancy, childbirth, miscarriage, or complications of abortion.

Skilled nursing (SNF), Long term acute (LTAC), Acute rehab Prior authorization required.
Behavioral health

NHS does not process prior authorization.

Prior authorization is processed through BHO: 702 364-1484.

Additional services

All transplant services, including consults Prior authorization required.
All air ambulance transports Prior authorization required.
Autism treatment, including ABA Prior authorization required for ABA visits over 80 per calendar year.
Bariatric surgery Weight reduction, including bariatric surgery is not covered.
Clinical trials Prior authorization required.
Hospice inpatient/​outpatient Prior authorization required.
Neuromonitoring Prior authorization required.
OOA/OON requests Prior authorization required.
PFT (Pulmonary function tests) No prior authorization required.
Sleep studies Prior authorization required.
Total joints (knees, hips, etc.) done at Ambulatory Surgery Center (ASC) Prior authorization required.