Culinary Health Fund prior authorization rules

Prior authorization rules by place of service

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

PLEASE BE ADVISED THAT THE CULINARY HEALTH FUND DOES NOT HAVE OUT OF AREA/NETWORK BENEFITS AND REQUIRES ALL PROVIDERS TO REFER TO IN-NETWORK PROVIDERS. FOR A CURRENT LIST OF PROVIDERS PLEASE GO TO www.CulinaryHealthFund.org OR CALL CUSTOMER SERVICE AT 702-733-9938.

In Office or Freestanding Facility

CARDIOLOGY SERVICES

ALL CARDIOLOGY SERVICES MUST BE PROVIDED BY HEART CARE IPA (HEART CENTER OF NEVADA AND NEVADA HEART & VASCULAR CENTER).

CARDIAC IMAGING SERVICES DO NOT REQUIRE PRIOR AUTHORIZATION WHEN PERFORMED BY THESE EXCLUSIVE PROVIDERS.

CUSTOM COMPRESSION STOCKINGS*

AUTHORIZATION REQUIRED
*LIMITED TO FUND CONTRACTED PROVIDERS

CYBERKNIFE

NO AUTHORIZATION REQUIRED WHEN PERFORMED BY COHEN, CURTIS, FARZIN, MEOZ AND SCHWARTZ (TIN: 27223260)

DME*

Durable medical equipment items that are over $500 require authorization (whether it is a rental or purchase, to include oxygen equipment over $500, i.e. oxygen concentrators)
*LIMITED TO FUND CONTRACTED PROVIDERS

HOME EEG MONITORING

AUTHORIZATION REQUIRED

HEMATOLOGY/​ONCOLOGY SERVICES

ALL HEMATOLOGY/​ONCOLOGY NOT PROVIDED BY COMPREHENSIVE CANCER CENTERS OF NEVADA REQUIRES PRIOR AUTHORIZATION.

HYPERBARIC TREATMENT

AUTHORIZATION REQUIRED

LABORATORY SERVICES

CLINICAL PATHOLOGY LABORATORIES IS THE CULINARY HEALTH FUND'S EXCLUSIVE LABORATORY PROVIDER AND MUST BE USED FOR ALL OUTPATIENT LABORATORY SERVICES

LABORATORY - ALL GENETIC TESTING*

AUTHORIZATION REQUIRED
*LIMITED TO FUND CONTRACTED PROVIDERS

OFFICE ADMINISTERED DRUGS

DRUGS INDICATED REQUIRE AUTHORIZATION:
Biologics and Implantable Hormone Replacement Therapy
PLEASE CALL HEALTHCARE SERVICES AT 702-892-7313 IF YOU HAVE QUESTIONS REGARDING COVERAGE OF A SPECIFIC DRUG.

ORTHOTIC & PROSTHETIC APPLIANCES*

Orthotic & Prosthetic Appliances that are over $500 require authorization
*LIMITED TO FUND CONTRACTED PROVIDERS

RADIOLOGY SERVICES

DESERT RADIOLOGISTS IS THE CULINARY HEALTH FUND'S EXCLUSIVE RADIOLOGY SERVICES PROVIDER. SERVICES PERFORMED AT DESERT RADIOLOGISTS DO NOT REQUIRE AUTHORIZATION WITH THE EXCEPTION OF PET SCANS.

For Radiology Services NOT performed at Desert Radiology authorization is required for: CT/CTA, Discography, Some Obstetrical Ultrasounds, Fetal Biophysical Profiles, MRI/MRA, PET Scans

SLEEP STUDIES

NOCTURNA IS THE CULINARY HEALTH FUND'S EXCLUSIVE SLEEP STUDY PROVIDER. Requires authorization and must be ordered by a Cardiologist, ENT, Neurologist, Pulmonologist or Culinary Health Center - Primary Care.

SURGERY

AUTHORIZATION REQUIRED FOR CERTAIN PROCEDURES.

VARICOSE VEINS

AUTHORIZATION REQUIRED - LIMITED TO SELECT SPECIALTIES

TMJ PROCEDURES

AUTHORIZATION REQUIRED

HOME HEALTH AND HOME INFUSION SERVICES (PLACE OF SERVICE 12)

AUTHORIZATION REQUIRED

INPATIENT (PLACE OF SERVICE 21, 31, 61)

ALL INPATIENT ADMISSIONS REQUIRE AUTHORIZATION, INCLUDING ELECTIVE ADMISSIONS AND THOSE RESULTING FROM ER OR OBSERVATION STAY

OBSERVATION (PLACE OF SERVICE 22)

ALL OBSERVATION ADMISSIONS REQUIRE AUTHORIZATION

OUTPATIENT HOSPITAL (PLACE OF SERVICE 22)

HYPERBARIC TREATMENT

AUTHORIZATION REQUIRED

RADIOLOGY SERVICES

DESERT RADIOLOGISTS IS THE CULINARY HEALTH FUND'S EXCLUSIVE RADIOLOGY SERVICES PROVIDER. SERVICES PERFORMED AT DESERT RADIOLOGISTS DO NOT REQUIRE AUTHORIZATION WITH THE EXCEPTION OF PET SCANS.

For Radiology Services not performed at Desert Radiology authorization is required for: CT/CTA, Discography, Fetal Biophysical Profiles, MRI/MRA, PET Scans

SLEEP STUDIES

NOCTURNA IS THE CULINARY HEALTH FUND'S EXCLUSIVE SLEEP STUDY PROVIDER. Requires authorization and must be ordered by a Cardiologist, ENT, Neurologist, Pulmonologist or Culinary Health Center - Primary Care.

SURGERY & INVASIVE DIAGNOSTIC PROCEDURES

AUTHORIZATION REQUIRED (Exception: Colonoscopy and EGD procedures do not require prior authorization.)

AMBULATORY SURGERY CENTER (PLACE OF SERVICE 24)

"AUTHORIZATION REQUIRED (Exception: Colonoscopy and EGD procedures do not require prior authorization.)

DIALYSIS CENTER (PLACE OF SERVICE 65)

AUTHORIZATION NOT REQUIRED FOR CONTRACTED FACILITIES

INDEPENDENT LABORATORY (PLACE OF SERVICE 81)

CLINICAL PATHOLOGY LABORATORIES IS THE CULINARY HEALTH FUND'S EXCLUSIVE LABORATORY PROVIDER AND MUST BE USED FOR ALL OUTPATIENT LABORATORY SERVICES

ALL GENETIC TESTING

AUTHORIZATION REQUIRED

BEHAVIORAL HEALTH SERVICES (PLACE OF SERVICE 51, 52, 53, 54, 55, 56, 57)

INPATIENT & OUTPATIENT BEHAVIORAL HEALTH SERVICES

All behavioral health services require authorization through Harmony Healthcare 702-251-8000

TRANSPLANT SERVICES

AUTHORIZATION IS REQUIRED FOR ALL TRANSPLANT SERVICES INCLUDING CONSULTS

The table is only a general guideline to Culinary Health Fund's 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 is not liable. The presence or absence of a procedure code and/or service on this list does not determine benefits or coverage for your patient. Verification of benefits and eligibility should be obtained by calling Customer Service at 702-733-9938.

CULINARY HEALTH FUND EXCLUSIVE PROVIDERS

CARDIOLOGY SERVICES - HEART CARE IPA

Heart Center of Nevada: 702-433-0022

Nevada Heart & Vascular Center: 702-227-3422

DURABLE MEDICAL EQUIPMENT

Adapt Health: 702-382-4940

Aveanna Healthcare: 866-883-1188

Everything Medical: 702-366-1111

Gabel Distributors: 702-489-2288

Preferred Homecare: 702-951-6900

LABORATORY SERVICES

Clinical Pathology Laboratories: 702-795-4900

LABORATORY SERVICES- GENETIC TESTING

Ambry Genetics: 866-262-7943 (BRCA and other select tests)

Sequenom Laboratories: 877-821-7266 (MaterniT 21 Plus & HerediT)

PROSTHETIC AND ORTHOTIC APPLIANCES

Brace It: 702-478-5848

Precision Orthotics & Prosthetics: 702-243-7671

Prosthetic Centers of Excellence: 702-384-1410

RADIOLOGY SERVICES

Desert Radiologists: 702-387-6900

SLEEP STUDIES

Nocturna: 702-896-7378