Exclusions List | Out of Network Prior Authorization
Updated 5/27/2025
The following services will not require out-of-network authorization:
- Family Planning Services
- Anything billed with family planning diagnosis codes
- Vaccines and Administrative Services
- Includes administration of medication and medication management
- Dialysis
- Emergency Room
- Urgent Care
- Ambulance/Emergency Transport Services
- Prior authorization for out of network providers is required for fixed wing codes
- Basic Radiology Services
- Basic Lab Services
- Prior authorization for out of network providers is required for genetic and drug testing codes
- Prior authorization for out of network providers is required for non-participating independent labs
- Anesthesia Services
- Prior authorization for out of network providers is required for pain management codes
- Hearing Aids
- Psychotherapy – Individual & Group
- Psych Testing
- Any service at Federally Qualified Health Center (FQHC)
- Any service at Rural Health Center (RHC)
- Any service at Tribal Health Center (THC)
- ESPDT Services
- Will be reviewed for all members <21 years and not denied solely for OON, there must be a medical reason not to approve
Correction Notice: A previous version of this communication listed High-tech Imaging (MRI, MRA, and PET scans) as excluded. The document has been corrected.