Prior Authorization

Culinary Health Fund Prior Authorization
Rules by Place of Service

For Prior Authorization please contact
NEVADA HEALTH SOLUTIONS:
Via phone (702) 216-1653 or toll free (855) 392-0778
Via fax (702) 691-5614
Via web portal at http://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)
CARDIOLOGY SERVICES ALL CARDIOLOGY SERVICES MUST BE PROVIDED BY HEART CARE IPA (ADVANCED CARDIOVASCULAR SPECIALISTS, 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
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
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 Impantable 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 All requests for sleep studies require authorization and must be ordered by a Neurologist, Pulmonologist or ENT
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 All requests for sleep studies require authorization and must be ordered by a Neurologist, Pulmonologist or ENT
SURGERY & INVASIVE DIAGNOSTIC PROCEDURES AUTHORIZATION REQURIED

AMBULATORY SURGERY CENTER (PLACE OF SERVICE 24)
AUTHORIZATION REQUIRED

DIALYSIS CENTER (PLACE OF SERVICE 65)
AUTHORIZATION REQUIRED

INDEPENDENT LABORATORY (PLACE OF SERVICE 81)
CLINICAL PATHOLOGY LABORATORIES (CPL) IS THE CULINARY HEALTH FUND’S EXCLUSIVE LABORATORY PROVIDER 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
Advanced Cardiovascular Specialists: 702-733-8600
Heart Center of Nevada: 702-433-0022
Nevada Heart & Vascular Center: 702-227-3422
DURABLE MEDICAL EQUIPMENT Apria Healthcare: 702-736-4466
Bennett Medical: 702-382-4940
Gabel Distributors: 702-489-2288
Preferred Homecare: 702-951-6900
THC of Nevada: 702-796-1016
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 & ORTHOTIC APPLIANCES Precision Orthotics & Prosthetics: 702-243-7671
Prosthetic Centers of Excellence: 702-384-1410
RADIOLOGY SERVICES Desert Radiologists: 702-387-6900