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Precertification Procedures

The following services require precertification as soon as possible in advance of providing the services:
Effective January 1, 2014

  1. Inpatient
    • Medical
    • Surgical
    • Maternity and newborn hospitalizations that exceed the standard length of stay
    • Rehabilitation
    • Hospice inpatient
    • Skilled Nursing Facility
    • Long Term Acute Care (LTAC)
  2. Behavioral Health- Inpatient and Intensive Outpatient (IOP)
  3. Chemical Dependency
    • Inpatient
    • Intensive Outpatient (IOP)
    • Methadone Maintenance
  4. Transplants
  5. Imaging
    • MRI/MRA
    • PET Scan
    • SPECT Scan
    • CT/CTA
    • Bone Scan
  6. Genetic Testing
  7. Some Outpatient Surgical Procedures
  8. Durable Medical Equipment purchases over $750
  9. Durable Medical Equipment rentals
  10. Covered Cosmetic Procedures
  11. Colonoscopy
  12. EGD
  13. Audiogram
  14. Sleep Study
  15. Medical Nutrition
  16. Hyperbaric oxygen therapy
  17. Physical therapy
  18. Speech therapy
  19. Occupational therapy
  20. Home Health Services
  21. Hospice
  22. Home Infusion
  23. Ambulance
    • Nonemergent transportation
    • Air transport
  24. Drugs and medical injectables:
    • Abatacept- (Orencia)
    • Adalimumab- (Humira)
    • Agalsidase Beta- (Fabrazyme)
    • Alglucerase- (Ceredase)
    • Alefacept- (Amevive)
    • Alglucosaidase Alfa (Lumizyme)
    • Alpha 1- Proteinase Inhibitor Human (Aralast, Aralast NP, Prolastin, Zemaira,Glassia)
    • Amphotericin B Lipid Complex – (Abelcet)
    • Belimumab- (Benlysta)
    • Botulinum Toxin Type A- (Botox)
    • Abobotulinum Toxin A- (Dysport)
    • Botulinum Toxin Type B (Myobloc)
    • Incobotulinum Toxin A- (Xeomin)
    • C-1 Esterase inhibitor – (Cinryze)
    • Certolizumab Pegol- (Cimzia)
    • Chorionic Gonadotropin (Novarel, Pregnyl, Profasi)
    • Collagenase Clostridium Histolyticum- (Xiaflex)
    • Denosumab- (Xgeva)
    • Eculizumab- (Solaris)
    • Epoprostenol- (Flolan)
    • Galsulfase- (Naglazyme)
    • Immune Globulin (Privigen)
    • Immune Globulin (Gammaplex)
    • Immune Globulin- (Hizentra)
    • IG Gamunex-C/Gammaked
    • IG Vivaglobin
    • IG Carimune, Carimune Classic, Carimune NF, Gammar, Iveegam En, Panglobulin NF, Polygam S/D
    • IG Octagam
    • IG Flebogamma/ Flebogamma DIF
    • Gatifloxacin (Tequin)
    • Hydroxyprogresterone Captoate- (Makena)
    • Ibandronate Sodium- (Boniva)
    • Idursulfase
    • Infliximab- (Remicade)
    • Imiglucerase- (Cerezyme)
    • Interferon Beat-1A- (Avonex)
    • Laronidase- (Aldurazyme)
    • Leuprolide Acetate- (Lupron Depot, Lupron Depot-PED)
    • Natalizumab- (Tysabri)
    • Omalizumab- (Xolair)
    • Pegademase Bovine- (Adagen)
    • Pegloticase- (Krystexxa)
    • Plerixa- (Mozobil)
    • Rilonacept- (Arcalyst)
    • Romiplastim- (NPlate)
    • Sargramostim- (Leukin)
    • Tocilizumab- (Actemra)
    • Ustekinumab- (Stelara)
    • Velaglucerase Alfa- (VPRIV)
    • Zoledronic Acid (Reclast)
    • Factor XIII- (Corifact)
    • Von Willebrand Factor Complex Wilate
    • Antihemophilic Factor VIII/Von Willebrand Factor Complex- (Alphanate)
    • Factor VIIA- (Novoseven)
    • Factor VIII AHF Human- (Alphanate, Hemofil M, Koate-DVI, Monarc-M, Monoclate-P)
    • Factor VIII AHF Porcine- (Hyate-C)
    • Factor VIII AHF Recombinant – (Advate, Helixate Fs, Kogenate FS, Kogenate FS w/Bioset, Recombinate, Refacto)
    • Factor IX non-recombinant- (Alphanine SD, Mononine)
    • Factor IX complex- (Bebulin VH, Profilnine SD, Proplex T)
    • Factor IX recombinant- (Benefix, Vitrasert)
    • Hemophilia Clotting Factor NOC
    • Hyualuronan or Derivative-Hyalgan, Supartz, Synvisc, Synvisc-One, Euflexxa, Orthovisc
    • Capsaicin- (Quetenza)
    • Treprostinil- (Tyvaso)
    • Fludarabine Phosphate- (Oforta)
    • Temozolomide- (Temodar)
    • Doxorubcin Hydrochloride- (Doxil)
    • Eribulin Mesylate- (Halaven)
    • Histrelin Implant (Supprelin LA)
    • Ipilimumab (Yervoy)
    • Pentostatin (Nipent)
    • Rituximab (Rituxan)
    • Canakinumab (Ilaris)
    • Sipuleucel- T (Provenge)

Note: This list may be amended by FirstCarolinaCare from time to time.

No precertification is needed for services for emergency medical conditions.

To request precertification, please call 1-800-574-8556 or 910-715-8100
From the prompt, select Option 1, at the next prompt select Option 2, wait for the next prompt and then select Option 1 OR fax a completed precertification request form to 1-866-896-1941.

All precertification requests must be made prior to starting the services listed above so that utilization review staff will have time to make a decision or get more information as required.