Welcome to HealthChoice Online Certification Portal

Certification is a review process used to determine if services are medically necessary according to HealthChoice guidelines. Certification is also referred to as prior authorization, precertification or preauthorization. All HealthChoice plans require certification for coverage of specified services. Certification approval does not guarantee benefits. Clinical editing and other plan policies, provisions and criteria apply.

Guidelines

Certification reviews are performed by either the HealthChoice Health Care Management Unit (HCMU) or the HealthChoice Certification Administrator, currently American Health Holdings (AHH), depending on the type of service. To request certification, complete the online request form or contact the appropriate certification unit noted below for the service(s) being requested. Certification requests that are not accurately completed or that are submitted to the incorrect area could be delayed or not processed.

For non-urgent services, certification requests must be initiated within three working days prior to the scheduled service. For urgent services, certification must be initiated within one day following the service. Services rendered in an emergency department and/or ambulance are not subject to certification requirements. For more information on certification, appeal rights and more refer to the HealthChoice Provider Manual.

If certification approval is not obtained for services that require it and/or if certification is denied either before or after the services are provided, claims for those services will be denied. For certifications approved after services are provided, a 10% penalty deduction on the allowable amount is applicable. Network providers are not allowed to impose certification penalties on members or their covered dependents.

For a more detailed list of the service codes that require certification, please refer to the HealthChoice Certification Code List found on the HealthChoice Fee Schedule site or call HealthChoice Customer Care.

Certification requests are reviewed by either the HCMU or AHH depending on service type. Services that are not accurately completed or that are submitted to the incorrect area could be delayed or not processed.

You now have the ability to upload documentation to HCMU Certification Requests. For more information on how to attached document(s), click here.

For services reviewed through the HealthCare Management Unit (HCMU) please select the appropriate link below:

Applied Behavioral Analysis
BRCA
Chiropractic
DME
Enteral Feeding
Esketamine
Genetic Testing
Home Health
Hospice
Hyperbaric Oxygen
Infusion Therapy
Mental Health
Occupational Therapy
Oral Surgery
Physical Therapy
Proton Beam Radiation
Speech Therapy
Substance Use Disorder
TMD/TMJ
Transcranial Magnetic Stimulation
Treatment/Medication

For services reviewed by AHH:
Click here for a certification request
Click here for a clinical update request

Services reviewed by the HealthChoice
Health Care Management Unit (HCMU)

See form links listed to the left or call HCMU at:
1-405-717-8879; or toll-free 1-800-543-6044 ext.8879
TDD: 1-405-949-2281, or toll-free 1-866-447-0436
Fax: 1-405-949-5459 or 1-405-949-5501

  1. Chiropractic Therapy
    a. Required only after initial 20 visits per calendar year.
    b. Visits are limited to 60 total per calendar year (some exceptions apply).
  2. Drugs and Medical Injectable
    a. Required for specified medications covered under the HealthChoice medical plan; this is not inclusive of requirements under the HealthChoice Pharmacy Benefits Administrator.
    b. Required for Botox Injections that are non-cosmetic and rendered in the Physician’s Office.
  3. Durable Medical Equipment
  4. Enteral Feeding
  5. Foot Orthotics
  6. Genetic Testing
  7. Glucose Monitors: Continuous
  8. Hearing Aids
  9. Home Health Care (Visits limited to 100 per calendar year)
  10. Home Intravenous (IV) Therapy (not subject to Home Health Care limits)
  11. Hyperbaric Oxygen Therapy (Outpatient)
  12. Mental Health Treatment
    a. Required for Outpatient services after initial 20 visits per calendar year.
    b. Required initially for Intensive Outpatient Therapy services.
    c. Required initially for TMS treatment.
    d. Required initially for esketamine.
    e. Required initially for Applied Behavior Analysis services.
  13. Occupational Therapy (Outpatient)
    a. Required after initial 20 visits per calendar year.
  14. Oral Splints and Appliances (some exceptions apply)
  15. Oral Surgery (Inpatient/Outpatient)
  16. Oxygen
  17. Physical Medicine/Physical Therapy (Outpatient)
    a. Required only after initial 20 visits per calendar year.
    b. Visits are limited to 60 total per calendar year (some exceptions apply).
  18. Prostheses and Orthopedic Appliances (some exceptions apply)
  19. Proton Beam Radiation Therapy
  20. Speech Therapy
    a. Required only for age seventeen (17) years or younger.
    b. Visits are limited to 60 total per calendar year (some exceptions apply).
  21. Substance Abuse Disorder Treatment
    a. Required for Outpatient services after initial 20 visits per calendar year.
    b. Required initially for intensive Outpatient Therapy services.
  22. Unlisted and Not Otherwise Specified - required for specified codes

Services reviewed by the HealthChoice Administrator (American Health Holdings)

See links listed to the left or call AHH at:
1-800-323-4314, option 2. TDD: toll-free 1-800-545-8279
Fax: 1-855-532-6780

  1. Bariatric Surgery (Eligibility criteria also required)
  2. Exhaustion of Medicare Lifetime Reserve Days
    a. Required for the additional 365 lifetime reserve days for hospitalization.
  3. HealthChoice is 2nd or 3rd Payer
    a. Required only after Medicare benefits are exhausted.
  4. Inpatient Admissions
  5. Maternity Care
    a. Required if patient and baby are not discharged within 48 hours of vaginal delivery or within 96 hours of C-section delivery.
  6. Mental Health Treatment (Inpatient, Residential, Partial Hospital)
  7. Myocardial PET Scan
  8. Observation Stays =/> 48 hours
  9. Outpatient Surgical Procedures:
    a. Blepharoplasty
    b. Mammoplasty (including reduction, removal of implants and symmetry)
    c. Correction of Lid Retraction
    d. Panniculectomy
    e. Rhinoplasty
    f. Septoplasty
    g. Varicose vein surgeries and procedures
         i. Including Sclerotherapy
    h. Sleep Apnea related surgeries, limited to:
         i. Radiofrequency Ablation (Coblation, Somnoplasty)
         ii. Uvulopalatopharyngoplasty (UPPP), including laser-assisted procedure
  10. Prophylactic and Gynecomastia Mastectomies
  11. Skilled Nursing Facility
  12. Spinal Surgical Procedures
    a. Cervical
    b. Lumbar
    c. Thoracic
  13. Spinal Cord Stimulator Placement and Revision
  14. Substance Use Disorder Treatment (Inpatient, Residential, Partial Hospital)
  15. Transplants
  16. Unlisted and Not Otherwise Specified - required for specified codes

back to home