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Health Providers Referral and Authorization Request Information

Referral vs. Prior Authorization

Referral is the process of sending a patient to another practitioner (ex. specialist) for consultation or a health care service that the referring source believes is necessary but is not prepared or qualified to provide. Your primary care physician will refer you to a participating specialist or a health care service provider if he or she cannot personally provide the care you need. Many referrals do not require an authorization number.

Authorization, also known as precertification, is a process of reviewing certain medical, surgical or behavioral health services to ensure medical necessity and appropriateness of care prior to services being rendered. The review also includes a determination of whether the service being requested is a covered benefit under your benefit plan. Authorizations are only required for certain services. Your physician will submit authorization/precertification requests electronically, by telephone, or in writing by fax or mail.

What to do next?

If the study your child will be receiving requires authorization, please contact the ordering provider to provide appointment details (appointment date/time) in order for the authorization process to begin. Unless, your insurance plan is primary care driven, in which, please contact the primary doctor to request authorization.

Please click on the desired health plan below to verify if prior authorization is required through your health plan for the most common outpatient diagnostic services. Any services not listed on the link, please contact the Authorization Unit at 786-624-3022 for more information.

*Please note that the information listed is general and that each plan group may have distinctive requirements that do not fall within these guidelines. For specific requirements, please contact your health plan directly.

Authorization Policies for Aetna U.S. Healthcare, Inc

Health Provider Website: https://www.aetna.com/
Accepted Health Plans: HMO PPO International

Does the diagnostic service require prior authorization?

MRI Scans: YES*
CT Scans: YES*
PET Scans: YES*
X-Rays: NO
Polysonograms YES**
Ultrasounds: NO
Physical Therapy: NO
Occupational Therapy: NO
Audio Evaluation: NO
Speech Evaluation: NO
Feeding and Swallowing Evaluation: NO

*Authorizations for high-end imaging (MRI, CT, PET Scans) are issued by Evicore. Please contact 1-800-575-4417 to obtain authorization.
**Authorizations for polysonograms are issued by Evicore. Please contact 1-800-575-4417 to obtain authorization.


International Policies

International policies require a verification of benefits letter (VOB) from the health plan confiriming eligibility and coverage for the desired services. Please contact your health plan directly in order to verify coverage.

Nicklaus Children's Hospital offers a Global concierge service, in which International patients can experience world renowned and comprehensive service. The Global Department will be able to help facilitate all of your healthcare needs. 

For more information, please contact the Global Health Department via e-mal at globalhealth@mch.com or by calling 305-662-8281.

Authorization Policies for Amerigroup Florida, Inc

Health Provider Website: https://www.amerigroup.com/
Accepted Health Plans: Medicaid Healthy Kids

Does the diagnostic service require prior authorization?

MRI Scans: YES*
CT Scans: YES*
PET Scans: YES*
X-Rays: NO
Polysonograms YES
Ultrasounds: NO
Physical Therapy: NO
Occupational Therapy: NO
Audio Evaluation: NO
Speech Evaluation: NO
Feeding and Swallowing Evaluation: NO

*Authorizations for high-end imaging (MRI, CT, PET Scans) are issued by American Imagining Management (AIM). Please contact 1-800-714-0040 to obtain authorization.


Authorization Policies for AvMed Health Plan

Health Provider Website: https://www.avmed.org/
Accepted Health Plans: HMO PPO

Does the diagnostic service require prior authorization?

MRI Scans: YES*
CT Scans: YES*
PET Scans: YES*
X-Rays: NO
Polysonograms NO
Ultrasounds: NO
Physical Therapy: NO
Occupational Therapy: NO
Audio Evaluation: NO
Speech Evaluation: NO
Feeding and Swallowing Evaluation: NO

*Authorizations for high-end imaging (MRI, CT, PET Scans) are issued by National Imaging Association (NIA). Please contact 1-866-663-8387 to obtain authorization.


Authorization Policies for Best Doctors, Inc.

Health Provider Website: http://www.bestdoctors.com/
Accepted Health Plans: International

Does the diagnostic service require prior authorization?

MRI Scans:
CT Scans:
PET Scans:
X-Rays:
Polysonograms
Ultrasounds:
Physical Therapy:
Occupational Therapy:
Audio Evaluation:
Speech Evaluation:
Feeding and Swallowing Evaluation:




International Policies

International policies require a verification of benefits letter (VOB) from the health plan confiriming eligibility and coverage for the desired services. Please contact your health plan directly in order to verify coverage.

Nicklaus Children's Hospital offers a Global concierge service, in which International patients can experience world renowned and comprehensive service. The Global Department will be able to help facilitate all of your healthcare needs. 

For more information, please contact the Global Health Department via e-mal at globalhealth@mch.com or by calling 305-662-8281.

Authorization Policies for Better Health

Health Provider Website: http://www.betterhealthflorida.com/
Accepted Health Plans: Medicaid

Does the diagnostic service require prior authorization?

MRI Scans: YES
CT Scans: YES
PET Scans: YES
X-Rays: YES
Polysonograms YES
Ultrasounds: YES
Physical Therapy: YES
Occupational Therapy: YES
Audio Evaluation: YES
Speech Evaluation: YES
Feeding and Swallowing Evaluation: YES

*Please note, all studies that are performed at our main campus, or any of our off-site centers, require authorization from this health plan.


Authorization Policies for Blue Cross and Blue Shield
Blue options

Health Provider Website: https://www.floridablue.com/
Accepted Health Plans: PPO Federal Exchange

Does the diagnostic service require prior authorization?

MRI Scans: YES*
CT Scans: YES*
PET Scans: YES*
X-Rays: NO
Polysonograms YES**
Ultrasounds: NO
Physical Therapy: NO
Occupational Therapy: NO
Audio Evaluation: NO
Speech Evaluation: NO
Feeding and Swallowing Evaluation: NO

*Authorizations for high-end imaging (MRI, CT, PET Scans) are issued by National Imaging Association (NIA). Please contact 1-866-326-6302 to obtain authorization.
**Authorizations for polysonogram studies are issued by Care Centrex. Please contact 1-855-243-3326 to obtain authorization.


Authorization Policies for Blue Cross and Blue Shield
Federal plan

Health Provider Website: https://www.floridablue.com/
Accepted Health Plans: PPO

Does the diagnostic service require prior authorization?

MRI Scans: NO
CT Scans: NO
PET Scans: NO
X-Rays: NO
Polysonograms NO
Ultrasounds: NO
Physical Therapy: NO
Occupational Therapy: NO
Audio Evaluation: NO
Speech Evaluation: NO
Feeding and Swallowing Evaluation: NO




Authorization Policies for Blue Cross and Blue Shield
Network Blue

Health Provider Website: https://www.floridablue.com/
Accepted Health Plans: PPO

Does the diagnostic service require prior authorization?

MRI Scans: YES*
CT Scans: YES*
PET Scans: YES*
X-Rays: NO
Polysonograms YES**
Ultrasounds: NO
Physical Therapy: NO
Occupational Therapy: NO
Audio Evaluation: NO
Speech Evaluation: NO
Feeding and Swallowing Evaluation: NO

*Authorizations for high-end imaging (MRI, CT, PET Scans) are issued by National Imaging Association (NIA). Please contact 1-866-326-6302 to obtain authorization.
**Authorizations for polysonogram studies are issued by Care Centrex. Please contact 1-855-243-3326 to obtain authorization.


International Policies

International policies require a verification of benefits letter (VOB) from the health plan confiriming eligibility and coverage for the desired services. Please contact your health plan directly in order to verify coverage.

Nicklaus Children's Hospital offers a Global concierge service, in which International patients can experience world renowned and comprehensive service. The Global Department will be able to help facilitate all of your healthcare needs. 

For more information, please contact the Global Health Department via e-mal at globalhealth@mch.com or by calling 305-662-8281.

Authorization Policies for Blue Cross and Blue Shield
of Florida Health Options, Inc.

Health Provider Website: https://www.floridablue.com/
Accepted Health Plans: HMO

Does the diagnostic service require prior authorization?

MRI Scans: YES*
CT Scans: YES*
PET Scans: YES*
X-Rays: NO
Polysonograms YES
Ultrasounds: YES
Physical Therapy: YES
Occupational Therapy: YES
Audio Evaluation: YES
Speech Evaluation: YES
Feeding and Swallowing Evaluation: YES

*Authorizations for high-end imaging (MRI, CT, PET Scans) are issued by National Imaging Association (NIA). Please contact 1-866-326-6302 to obtain authorization.


Please note, all studies that are performed at our main campus, or any of our off-site centers, require authorization from this health plan.

Authorization Policies for Blue Cross and Blue Shield
out of state

Health Provider Website: https://www.floridablue.com/
Accepted Health Plans:

Does the diagnostic service require prior authorization?

MRI Scans: CALL*
CT Scans: CALL*
PET Scans: CALL*
X-Rays: CALL
Polysonograms CALL
Ultrasounds: CALL
Physical Therapy: CALL
Occupational Therapy: CALL
Audio Evaluation: CALL
Speech Evaluation: CALL
Feeding and Swallowing Evaluation: CALL

*Authorizations for high-end imaging (MRI, CT, PET Scans) are usually handled by a third party. Please contact the health plan directly for specifics regarding authorization submission


Out of state policies differ in authorization requirements dependent on the state. For all authorization requirements done in an outpatient hospital setting, please contact the health plan for details.

Authorization Policies for Blue Cross Blue Shield
Out of State

Health Provider Website: https://www.floridablue.com/
Accepted Health Plans: HMO PPO

Does the diagnostic service require prior authorization?

MRI Scans: CALL*
CT Scans: CALL*
PET Scans: CALL*
X-Rays: CALL
Polysonograms CALL
Ultrasounds: CALL
Physical Therapy: CALL
Occupational Therapy: CALL
Audio Evaluation: CALL
Speech Evaluation: CALL
Feeding and Swallowing Evaluation: CALL

*Authorizations for high-end imaging (MRI, CT, PET Scans) are usually handled by a third party. Please contact the health plan directly for specifics regarding authorization submission.
Out of state policies differ in authorization requirements dependent on the state. For all authorization requirements done in an outpatient hospital setting, please contact the health plan for details.


Authorization Policies for Cigna Healthcare

Health Provider Website: http://www.cigna.com/
Accepted Health Plans: HMO PPO Federal Exchange International

Does the diagnostic service require prior authorization?

MRI Scans: YES*
CT Scans: YES*
PET Scans: YES*
X-Rays: NO
Polysonograms YES**
Ultrasounds: NO
Physical Therapy: NO
Occupational Therapy: NO
Audio Evaluation: NO
Speech Evaluation: NO
Feeding and Swallowing Evaluation: NO

*Authorizations for high-end imaging (MRI, CT, PET Scans) are issued by Evicore. Please contact 1-888-693-3297 to obtain authorization.
**Authorizations for polysonogram studies are issued by Care Centrex. Please contact 1-877-877-9899 to obtain authorization.


International Policies

International policies require a verification of benefits letter (VOB) from the health plan confiriming eligibility and coverage for the desired services. Please contact your health plan directly in order to verify coverage.

Nicklaus Children's Hospital offers a Global concierge service, in which International patients can experience world renowned and comprehensive service. The Global Department will be able to help facilitate all of your healthcare needs. 

For more information, please contact the Global Health Department via e-mal at globalhealth@mch.com or by calling 305-662-8281.

Authorization Policies for CMS Network

Health Provider Website: http://www.floridahealth.gov/programs-and-services/childrens-health/cms-plan/eligibility-and-services/index.html
Accepted Health Plans: Medicaid Healthy Kids

Does the diagnostic service require prior authorization?

MRI Scans: YES
CT Scans: YES
PET Scans: YES
X-Rays: NO
Polysonograms NO*
Ultrasounds: NO
Physical Therapy: NO
Occupational Therapy: NO
Audio Evaluation: NO
Speech Evaluation: NO
Feeding and Swallowing Evaluation: NO

*South Florida Community Care Network plans do require authorization. Please contact 866-899-4828 to obtain authorization.


CMS network encompasses the following health plans: CMS Title 21, Children Medical Services Speciality Plan (Title 19), and South Florida Community Care Network.

Authorization Policies for Coventry HMO & PPO

Health Provider Website: http://coventryhealthcare.com/
Accepted Health Plans: HMO PPO Medicaid Healthy Kids International

Does the diagnostic service require prior authorization?

MRI Scans: YES*
CT Scans: YES*
PET Scans: YES*
X-Rays: NO**
Polysonograms YES
Ultrasounds: NO
Physical Therapy: NO
Occupational Therapy: NO
Audio Evaluation: YES
Speech Evaluation: NO
Feeding and Swallowing Evaluation: NO

*Authorizations for high-end imaging (MRI, CT, PET Scans) are issued by National Imaging Association (NIA). Please contact 1-800-642-7821 to obtain authorization.
**Authorization requirements are based on procedure code. Please contact the Authorization Unit for verification on whether or not your specific x-ray requires authorization


Authorization Policies for Coventry Medicaid & Healthy Kids

Health Provider Website: http://coventryhealthcare.com/
Accepted Health Plans: HMO PPO Medicaid Healthy Kids International

Does the diagnostic service require prior authorization?

MRI Scans: YES*
CT Scans: YES*
PET Scans: YES*
X-Rays: NO**
Polysonograms YES
Ultrasounds: NO***
Physical Therapy: YES
Occupational Therapy: YES
Audio Evaluation: YES
Speech Evaluation: YES
Feeding and Swallowing Evaluation: YES

*Authorizations for high-end imaging (MRI, CT, PET Scans) are issued by National Imaging Association (NIA). Please contact 1-800-642-7821 to obtain authorization.
**Authorization requirements are based on procedure code. Please contact the Authorization Unit for verification on whether or not your specific x-ray requires authorization
***Doppler ultrasounds do require authorization


Authorization Policies for Health Ease, Inc. of Florida

Health Provider Website: https://www.wellcare.com/Florida
Accepted Health Plans: Medicaid

Does the diagnostic service require prior authorization?

MRI Scans: YES*
CT Scans: YES*
PET Scans: YES*
X-Rays: NO
Polysonograms YES**
Ultrasounds: NO***
Physical Therapy: NO
Occupational Therapy: NO
Audio Evaluation: NO
Speech Evaluation: YES
Feeding and Swallowing Evaluation: NO

*Authorizations for high-end imaging (MRI, CT, PET Scans) are issued by Evicore. Please contact 1-888-333-2641 to obtain authorization.
**Authorizations for polysonograms are issued by Evicore. Please contact 1-888-333-8641 to obtain authorization.
***Doppler ultrasounds do require authorization.


Authorization Policies for Humana HMO

Health Provider Website: https://www.humana.com/
Accepted Health Plans: HMO PPO Medicaid

Does the diagnostic service require prior authorization?

MRI Scans: YES*
CT Scans: YES*
PET Scans: YES*
X-Rays: NO
Polysonograms NO
Ultrasounds: NO
Physical Therapy: NO
Occupational Therapy: NO
Audio Evaluation: NO
Speech Evaluation: NO
Feeding and Swallowing Evaluation: NO

*Authorizations for high-end imaging (MRI, CT, PET Scans) are issued by Health Help. Please contact 1-866-825-1550 to obtain authorization.


​Humana member's that have commericial policies that begin with the letter "H" may have different requirements then listed above. Please contact Humana directly for specific requirements.

Authorization Policies for Humana Medicaid

Health Provider Website: https://www.humana.com/
Accepted Health Plans: HMO PPO Medicaid

Does the diagnostic service require prior authorization?

MRI Scans: YES
CT Scans: YES
PET Scans: YES
X-Rays: YES
Polysonograms YES
Ultrasounds: YES
Physical Therapy: YES
Occupational Therapy: YES
Audio Evaluation: YES
Speech Evaluation: YES
Feeding and Swallowing Evaluation: YES




Please note, all studies that are performed at our main campus, or any of our off-site centers, require authorization from the Medicaid health plan.

Authorization Policies for Humana PPO

Health Provider Website: https://www.humana.com/
Accepted Health Plans: HMO PPO Medicaid

Does the diagnostic service require prior authorization?

MRI Scans: YES*
CT Scans: YES*
PET Scans: YES*
X-Rays: NO
Polysonograms NO
Ultrasounds: NO
Physical Therapy: NO
Occupational Therapy: NO
Audio Evaluation: NO
Speech Evaluation: NO
Feeding and Swallowing Evaluation: NO

*Authorizations for high-end imaging (MRI, CT, PET Scans) are issued by Health Help. Please contact 1-866-825-1550 to obtain authorization.


Authorization Policies for Molina Healthcare of Florida, Inc.

Health Provider Website: http://www.molinahealthcare.com/en-us/Pages/home.aspx?CookieCheck=true
Accepted Health Plans: Medicaid

Does the diagnostic service require prior authorization?

MRI Scans: YES
CT Scans: YES
PET Scans: YES
X-Rays: NO
Polysonograms YES*
Ultrasounds: NO
Physical Therapy: NO
Occupational Therapy: NO
Audio Evaluation: NO
Speech Evaluation: NO
Feeding and Swallowing Evaluation: NO

*Patients 5 years old or younger do not require authorization.


Authorization Policies for Neighborhood Health Partnership, Inc. [NHP]

Health Provider Website: https://www.mynhp.com/
Accepted Health Plans: HMO PPO

Does the diagnostic service require prior authorization?

MRI Scans: YES*
CT Scans: YES*
PET Scans: YES*
X-Rays: NO
Polysonograms YES
Ultrasounds: NO
Physical Therapy: NO
Occupational Therapy: NO
Audio Evaluation: NO
Speech Evaluation: NO
Feeding and Swallowing Evaluation: NO

*Authorizations for high-end imaging (MRI, CT, PET Scans) are issued by Evicore. Please contact 1-866-242-9546 to obtain authorization.


Authorization Policies for Preferred Medical Plan

Health Provider Website: http://www.pmphmo.com/
Accepted Health Plans: HMO

Does the diagnostic service require prior authorization?

MRI Scans: YES
CT Scans: YES
PET Scans: YES
X-Rays: YES
Polysonograms YES
Ultrasounds: YES
Physical Therapy: No Benefits
Occupational Therapy: No Benefits
Audio Evaluation: YES
Speech Evaluation: No Benefits
Feeding and Swallowing Evaluation: No Benefits




Please note, all studies that are performed at our main campus, or any of our off-site centers, require authorization from this health plan.

Authorization Policies for Prestige Health Choice, LLC

Health Provider Website: https://www.prestigehealthchoice.com/
Accepted Health Plans: Medicaid

Does the diagnostic service require prior authorization?

MRI Scans: YES
CT Scans: YES
PET Scans: YES
X-Rays: YES
Polysonograms YES
Ultrasounds: YES
Physical Therapy: YES
Occupational Therapy: YES
Audio Evaluation: YES
Speech Evaluation: YES
Feeding and Swallowing Evaluation: YES




Please note, all studies that are performed at our main campus, or any of our off-site centers, require authorization from the Medicaid health plan.

Authorization Policies for Simply Healthcare Plans, Inc.

Health Provider Website: http://www.simplyhealthcareplans.com/
Accepted Health Plans: Medicaid

Does the diagnostic service require prior authorization?

MRI Scans: YES
CT Scans: YES
PET Scans: YES
X-Rays: YES
Polysonograms YES
Ultrasounds: YES
Physical Therapy: YES
Occupational Therapy: YES
Audio Evaluation: YES
Speech Evaluation: YES
Feeding and Swallowing Evaluation: YES




Please note, all studies that are performed at our main campus, or any of our off-site centers, require authorization from this health plan.

Authorization Policies for Staywell

Health Provider Website: https://www.wellcare.com/Florida
Accepted Health Plans: Medicaid Healthy Kids

Does the diagnostic service require prior authorization?

MRI Scans: YES*
CT Scans: YES*
PET Scans: YES*
X-Rays: NO
Polysonograms YES**
Ultrasounds: NO***
Physical Therapy: NO
Occupational Therapy: NO
Audio Evaluation: NO
Speech Evaluation: YES
Feeding and Swallowing Evaluation: NO

*Authorizations for high-end imaging (MRI, CT, PET Scans) are issued by Evicore. Please contact 1-888-333-2641 to obtain authorization.
**Authorizations for polysonograms are issued by Evicore. Please contact 1-888-333-8641 to obtain authorization.
***Doppler ultrasounds do require authorization.


Authorization Policies for Sunshine State Health Plan

Health Provider Website: https://www.sunshinehealth.com/
Accepted Health Plans: Medicaid Healthy Kids

Does the diagnostic service require prior authorization?

MRI Scans: YES*
CT Scans: YES*
PET Scans: YES*
X-Rays: NO
Polysonograms NO
Ultrasounds: NO
Physical Therapy: NO
Occupational Therapy: NO
Audio Evaluation: NO
Speech Evaluation: NO
Feeding and Swallowing Evaluation: NO

*Authorizations for high-end imaging (MRI, CT, PET Scans) are issued by NIA Please contact 1-866-214-2569 to obtain authorization.


Authorization Policies for United HMO-PPO-Federal Exchange

Health Provider Website: https://www.myuhc.com/member/prewelcome.do
Accepted Health Plans: HMO PPO Federal Exchange Medicaid Healthy Kids International

Does the diagnostic service require prior authorization?

MRI Scans: YES*
CT Scans: YES*
PET Scans: YES*
X-Rays: NO
Polysonograms YES**
Ultrasounds: NO
Physical Therapy: NO
Occupational Therapy: NO
Audio Evaluation: NO
Speech Evaluation: NO
Feeding and Swallowing Evaluation: NO

*Authorizations for high-end imaging (MRI, CT, PET Scans) are issued by United Healthcare. Please contact 1-866-889-8054 to obtain authorization.
**Patients 5 years old or younger do not require authorization.


Authorization Policies for United Medicaid

Health Provider Website: https://www.myuhc.com/member/prewelcome.do
Accepted Health Plans: HMO PPO Federal Exchange Medicaid Healthy Kids International

Does the diagnostic service require prior authorization?

MRI Scans: YES*
CT Scans: YES*
PET Scans: YES*
X-Rays: NO
Polysonograms NO
Ultrasounds: NO
Physical Therapy: YES
Occupational Therapy: YES
Audio Evaluation: NO
Speech Evaluation: NO
Feeding and Swallowing Evaluation: NO

*Authorizations for high-end imaging (MRI, CT, PET Scans) are issued by United Healthcare. Please contact 1-866-889-8054 to obtain authorization.


International policies require a verification of benefits letter (VOB) from the health plan confiriming eligibility and coverage for the desired services. Please contact your health plan directly in order to verify coverage.
Nicklaus Children's Hospital offers a Global conceirge service, in which International patients can experience world renowned and comprehensive service. The Global Department will be able to help facilitate all of your healthcare needs.
For more information, please contact the Global Health Department at 305-662-8281 or visit https://www.nicklauschildrens.org/patients-and-families/global-health

Authorization Policies for Virgin Islands Medicaid Program

Health Provider Website: http://www.dhs.gov.vi/financial_programs/medical_assistance.html
Accepted Health Plans: Medicaid

Does the diagnostic service require prior authorization?

MRI Scans:
CT Scans:
PET Scans:
X-Rays:
Polysonograms
Ultrasounds:
Physical Therapy:
Occupational Therapy:
Audio Evaluation:
Speech Evaluation:
Feeding and Swallowing Evaluation:




International Policies

International policies require a verification of benefits letter (VOB) from the health plan confiriming eligibility and coverage for the desired services. Please contact your health plan directly in order to verify coverage.

Nicklaus Children's Hospital offers a Global concierge service, in which International patients can experience world renowned and comprehensive service. The Global Department will be able to help facilitate all of your healthcare needs. 

For more information, please contact the Global Health Department via e-mal at globalhealth@mch.com or by calling 305-662-8281.


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