Culinary Health Fund prior authorization rules

Prior authorization rules by place of service

Effective 02/01/2023

For Prior Authorization, please contact NEVADA HEALTH SOLUTIONS:
Telephone: 702-216-1653
Toll Free: 855-392-0778
Fax: 702-691-5614
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 (PLACE OF SERVICE 11)

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 (Exception: J0585, J9030, J9155 and J9217 FOR UROLOGY ONLY)
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 Services performed by a PPO Freestanding Radiology Facility do not require prior authorization
For Radiology Services NOT performed at a PPO Freestanding Radiology Facility 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 & WOUND CARE TREATMENT AUTHORIZATION REQUIRED
RADIOLOGY SERVICES Services performed by a PPO Freestanding Radiology Facility do not require prior authorization
For Radiology Services NOT performed at a PPO Freestanding Radiology Facility 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 & 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

DURABLE MEDICAL EQUIPMENT Adapt Health: 702-382-4940
Apria Healthcare: 702-736-4466
Aveanna Healthcare: 866-883-1188
Byrum Healthcare: 800-552-2633
Dia-Foot (diabetic shoes/‍inserts and custom orthotics): 702-970-7166
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)
PROSTHETIC AND ORTHOTIC APPLIANCES Brace It: 702-478-5848
Prosthetic Centers of Excellence: 702-384-1410
RADIOLOGY SERVICES Opensided MRI of Las Vegas (open-sided MRI services only): 702-932-2740
Pueblo Medical Imaging: 702-228-0031
SimonMed Imaging: 702-433-6934
Steinberg Diagnostic Medical Imaging (SDMI): 702-732-6000
SLEEP STUDIES Nocturna: 702-896-7378