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Johns Hopkins Health Plans

Outpatient Referral and Preauthorization Guideline Update

Effective May 1, 2020

The Outpatient Referral and Preauthorization Guidelines (OPRGs) clearly outline the referral and preauthorization requirements for many outpatient services for our Johns Hopkins Advantage MD, Johns Hopkins Employer Health Programs (EHP), Priority Partners and Johns Hopkins US Family Health Plan (USFHP) members. These guidelines are updated every quarter and posted to the Johns Hopkins Health Plans website.

Below is a summary of the changes to the Outpatient Referral and Preauthorization Guidelines that go into effect May 1, 2020:

Johns Hopkins Advantage MD:
  • Policies retired to InterQual criteria
    • Bone marrow and stem cell transplantation
    • Oxygen and oxygen supplies
    • International Normalized Ratio (INR) self-monitoring devices
  • No preauthorization required
    • Pulmonary rehabilitation
  • Preauthorization required
    • Panniculectomy
    • Partial Hospitalization Program (PMP)
Johns Hopkins EHP:
  • Policies retired to InterQual criteria
    • Bone marrow and stem cell transplantation
    • Oxygen and oxygen supplies
    • International Normalized Ratio (INR) self-monitoring devices
  • No preauthorization required
    • Radiation
      • Abdomen CT
      • Brain MRI
      • Cervical and lumbar spine MRI
      • Chest CT
      • Lower extremity MRI
      • Pelvis CT
      • Sinus cavity CT
    • Prostate surgery
    • External beam radiation therapy (prostate cancer only)
      • Three-dimensional conformal radiation therapy (3D-CRT)
      • Intensity modulated radiation therapy (IMRT)
      • Stereotactic radiation therapy (SBRT)
  • Preauthorization required
    • Panniculectomy
Priority Partners:
  • Policies retired to Interqual criteria
    • Bone marrow and stem cell transplantation
    • Oxygen and oxygen supplies
    • International Normalized Ratio (INR) self-monitoring devices
  • No preauthorization required
    • Otolaryngology
    • Prostate surgery
    • External beam radiation therapy (prostate cancer only)
      • Three-dimensional conformal radiation therapy (3D-CRT)
      • Intensity modulated radiation therapy (IMRT)
      • Stereotactic radiation therapy (SBRT)
  • Preauthorization required
    • Panniculectomy
Johns Hopkins USFHP:
  • Policies retired to Interqual criteria
    • Bone marrow and stem cell transplantation
    • Oxygen and oxygen supplies
    • International Normalized Ratio (INR) self-monitoring devices
  • No preauthorization required
    • Prostate surgery
    • External beam radiation therapy (prostate cancer only)
      • Three-dimensional conformal radiation therapy (3D-CRT)
      • Intensity modulated radiation therapy (IMRT)
      • Stereotactic radiation therapy (SBRT)
  • Preauthorization required
    • Panniculectomy
    • Breast tomosynthesis < 40 years of age

*For related medical policies, please go to www.hopkinshealthplans.org > For Providers > Policies.