2026 CODAC Benefit Summaries and Carrier Flyers

• Concurrent review, based on the admitting diagnosis, of services requested by the treating Physician in a medical care facility; and • Planning for discharge from a medical care facility or cessation of medical treatment.

How to Prior Authorize

The health care Provider, Covered Person, or someone on the Covered Person’s behalf (e.g., family member) must call the Utilization Review Administrator, MedWatch, at the phone number listed on the back of the Plan identification card or online at www.urmedwatch.com.to receive certification of services that will be delivered in a medical care facility. This call must be made in advance of services being rendered.

The following information is needed:

• The name of the Covered Person and the relationship to the covered Employee; • The name, Employee identification number, and address of the covered Employee; • The name of the employer; • The name, address, TIN, NPI, and telephone number of the treating Physician; • The name of the medical care facility, proposed date of admission, and the proposed length of stay; and • The proposed medical services, diagnosis code(s), and procedure code(s).

The following services require prior authorization prior to the services being rendered:

• All inpatient stays for medical and psych and substance abuse. • All surgeries not done in a doctor’s office . • All services listed below regardless of place of service. • Arthroscopy or any joint surgery. • Biopsies - recommended where potential Cancer diagnosis exists. • Bladder Repair. • Cardiac Cath/Angioplasty. • Deviated Septum/Nasal Surgery. • EBCT (Electron Beam Tomography). • Endoscopic Procedures/Colonoscopy. • Laminectomy/Spinal Surgery. • Laparoscopy. • MRI/CT/Pet Scan - excludes bone density studies. • All Physical/Occupational/Speech Therapies. • PT/OT/ST sessions #14- 25 require Nurse Review. • Sessions #26 and beyond require MNR via CM. • Trigger Point Injections. • 23-hour observation stays. • Genetic testing. • Non-Emergent Air Transportation. • Chemotherapy. • Select Implants. • Transplants (except corneal). • Infusions (Infusion Therapy) of any type > $1,500. • Pain Management such as: • Epidural Steroid Injections. • Facet Injections. • Radiofrequency Ablations (RFA). • Medial Branch Blocks. • SI Join Injections. • Sympathetic Nerve Blocks. • Spinal Cord Stimulators. • Intrathecal/Epidural Catheter & Drug Infusion Pumps.

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