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What is prior authorization?
What is 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 prior authorization for all out-of-network services, except for family planning and emergencies. If you don’t get prior authorization, you may have to pay for services that:
- You get from a provider who isn’t in our network
- Need prior authorization
- Your plan doesn’t cover
Your provider must check to see if the service needs prior authorization before they provide it. 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 member materials and forms page.
You can also get a copy of our review criteria. Just call 1-855-221-5656 (TTY: 711). We’re here for you 24 hours a day, 7 days a week.
How prior authorization works
How prior authorization works
Here’s what you can expect from the prior authorization process:
- Your provider will give us info about the services they think you need.
- We review the info.
- You and your provider will get a letter when we approve or deny a service.
- If we deny your request, we’ll explain our reasons in the letter.
- If we deny a request, you or your provider can file an appeal.
Right care, right place, right time
Right care, right place, right time
Prior authorization is the process we use to make sure you get covered quality services that are medically necessary, before you get them. 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
Our goal is to help you be as healthy as you can be. So we want to be sure you get the right care at the right place at the right time. You and your provider can talk about all treatment options, whether we cover them or not.
Questions? Just call us at 1-855-221-5656 (TTY: 711).