Prior authorization

Some services and supplies need approval from your health plan first. This means your providers need permission to provide certain services. They’ll know how to do this. And we’ll work together to make sure the service is what you need.

You need PA for all out-of-network services, except for family planning and emergencies. If you don’t get PA, you may have to pay for services that:

• An out-of-network provider gives
• Need PA
• Your plan doesn’t cover
  

Your provider must check to see if the service needs PA before they provide it. We update the list of services that need PA from time to time. They can get the full list on their Provider Portal. 

Want to get the most current list, too? Just check your member handbook on our materials and forms page.

Materials and forms

PA is a type of review process that’s called utilization management (UM). It allows us to be sure you’re getting the right care at the right place, and at the right time, before you get it. 

UM is the process we use to make sure you get covered quality services that are medically necessary. And we use national guidelines to be sure we’re doing the right thing. We make decisions about health care based on: 

• The most appropriate care
• Services available
• Benefit coverage
  

You may have concerns about our practices. We want to assure you that we don’t:

• Reward any providers or staff for denying coverage or services
• Give money to providers or staff to make decisions that keep you from getting the right care
• Hire, promote or end contracts with providers based on the likelihood they’ll deny your benefits