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Prior authorization

Some types of care need prior authorization (PA), or approval, before you receive them. Read on to learn more about PA.

What is PA?

What is PA?

Some services and supplies need approval from your health plan first. Here are some common things that need PA:

 

  • Overnight hospital stays 

  • Services outside of our service area

  • Major surgeries 

  • Specialist visits

  • Expensive medication 

 

Your provider must check to see if PA is needed before they provide the service. They can get the full list on their Provider Portal. 

 

You can get the most current list, too. Just check your member handbook on our Member materials and forms page. Or call us at 1-855-300-5528 (TTY: 711). We’re here Monday through Friday, 7 AM to 7 PM ET.

 

You never need PA for emergencies, even when you’re outside of our network.

How PA works

How PA works

Here’s what you can expect from the PA process: 

 

  • Your provider will give us info about the care they think you need. 

  • One of our plan providers will review the info. If they don’t think the care is medically necessary, another plan provider will review the info. 

  • We’ll decide within 2 business days after we receive your request.  

  • If we need more info, we’ll ask your provider for it. They’ll have 14 days to submit the info. If we receive more info, we’ll consider it and reply within 2 business days. If we don’t receive more info, we’ll approve or deny the care based on the info we have. 

  • You and your provider will get a letter or call with approval or denial of the care. If we deny your care, we’ll explain why.  

  • You can also file an appeal if we deny the care. Your PCP can file an appeal for you, with your written permission. 

Right care, right place, right time

Right care, right place, right time

PA is a type of 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 nationally recognized 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  

 

We don’t reward any providers or staff for denying coverage or services. We also don’t give money to providers or staff to make decisions that keep you from getting the right care. And finally, we don’t 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 you to have the right care.

 

Questions? Just call us at 1-855-300-5528 (TTY: 711). If you call after hours, leave a message. We’ll call you back the next business day.