Trilogy Prior Authorization List

Please note that precertification, preadmission, preauthorization and notification requirements all refer to the same process of preauthorization. As a participating provider, you are responsible for Prior Authorization of in-plan services. Trilogy Members are responsible for Prior Authorization for out-of-plan services on this list.

To obtain Prior Authorization for Trilogy Health Insurance members, please call 866-802-1326 .

Inpatient Admissions:

Acute Hospital

Skilled Nursing Facility (SNF)

Acute Rehabilitation

Long-Term Acute Care

Hospice Care

Transplants

Newborn Stays (beyond mother)

Behavioral Health/AODA:

Inpatient Hospital Admission

Outpatient Treatment (Includes partial hospitalization)

Residential Facility/Transitional

Other Outpatient Procedures:

Cardiac Rehabilitation

Chemotherapy/Radiation

Dialysis

Pain Management/Spinal Procedures:

Spinal Fusion

Decompression Surgeries

Facet Injections

Epidural Injections (provider office and outpatient)

Kyphoplasty

Vertebroplasty

Pain Infusion Pump (back and neck pain only)

Spinal Cord Stimulator

Outpatient Surgical Procedures:

Blepharoplasty

Breast Reconstruction

Sclerotherapy or surgery for varicose veins

Plasmaphoresis/IVIG

Otoplasty

Rhinoplasty

Septoplasty

Uvulopalatopharyngoplasty/Uvulopharyngoplasty

Diastasis Recti Repair

Cardiac Ablations

Cardiac Devices (Pacemakers & Defibrillators)

Outpatient Diagnostics:

MRI

MRA

PET Scans

DEXA Scans

Other Services:

Durable Medical Equipment > $1,000

Home Health Care Services

Prosthetics

Autism Spectrum Disorders Treatment

Hearing Aids

Cochlear Implants

OT/PT/ST – submit treatment plans after first visit

Chiropractic - submit treatment plans after first visit

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