Skip to Main Content

Prior Authorizations and Referrals

Medical and Behavioral Health Care Services

When you need health care, always start with a call to your medical or behavioral health provider. You can choose any provider in our behavioral health network. You don’t need a referral from your primary care provider (PCP).

Prior Authorization and Referrals

Some covered services or medications may need approval from NH Healthy Families, and this is called a Prior Authorization. You do not need a paper referral from NH Healthy Families to see a provider but your provider may need to request a prior authorization from NH Healthy Families for a service to be approved. Below is a list of services that require prior authorization from NH Healthy Families before your healthcare provider can proceed with treatment.

Inpatient Hospitalization

Pre-scheduled, optional services must be approved by NH Healthy Families before you are admitted. Your provider will send a request to NH Healthy Families.

How soon can I expect to be seen by a specialist?

In some situations, the specialist may see you right away. Depending on the medical need, it may take up to 30 days to schedule the appointment to see the specialist.

How do I ask for a second opinion?

You have the right to a second opinion from a NH Healthy Families provider if you are not satisfied with the plan of care offered by the specialist. Your primary care healthcare provider should be able to give you the name of a provider for a second opinion visit. If your primary care provider wants you to see a specialist that is not a NH Healthy Families provider; that visit will have to be approved in advance by NH Healthy Families.

Non-Participating/Out-of-Network Providers

Requests for services from a provider, facility, or vendor that is not in the NH Healthy Families network need to be approved by getting a prior authorization.

Your healthcare provider can tell you if a medical service or prescription needs prior authorization. The list below gives you general categories of services requiring prior authorization. Please keep in mind that services and benefits change from time to time. This prior authorization list is for your general information only. Please call NH Healthy Families Member Services for the most up to date information at 1-866-769-3085. 

New Hampshire Healthy Families Services that require a Prior Authorization

Note that services that have “(HPP)” after the description are noted for prior approval for the New Hampshire Health Protection Program only.  All others include information on prior authorization for Standard Medicaid and the New Hampshire Health Protection Program.

Services that require a Prior Authorization

Prior Authorization Required for Some or All of the Services?

Ambulatory Surgery Center  Some services require prior authorization.
Bariatric
Surgery (Certain restrictions and limitations may apply)
Yes
Birthing Centers  Yes
Durable Medical Equipment (DME)
Some items require prior authorization.
High Cost Radiology
Yes
Home Health Care Services
Yes
Hospice Care
Yes
Hospital Services Inpatient
Yes
Hospital Services Outpatient
Some services require prior authorization.
Laboratory Services (HPP):  All services necessary for the diagnosis, treatment and prevention of disease, and for the maintenance of health. Some services require prior authorization.
Maternity Services (HPP)
Some services require prior authorization.
Medical Services Clinic
Yes
Orthotics & Prosthetics (O&P):  Braces (non-dental) and other mechanical or molded devices to support or correct any defect of form or function of the human body.
Yes
Oxygen & Respiratory Services (HPP)
Some services require prior authorization.
Pain Management
Some services require prior authorization.
Substance Use Disorder Services (HPP)
Some services require prior authorization.
Therapy (OT, PT,ST) Services (Outpatient)
Yes
Transplant Services
Yes

All such services determined by NHHF to be medically necessary shall constitute a NHHF Covered Service.  See the New Hampshire Healthy Families Member Handbook for more information on coverage out-of-network and out of the NHHF service area.