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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. 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 for these out-of-network services, you may have to pay for them.


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 1-855-232-3596 (TTY: 711). We’re here  24 hours a day, 7 days a week.

How PA works

How PA works

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


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

  • We review the info.

  • If we can’t approve the request, a different health plan provider will 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

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.


You and your provider can talk about all treatment options, whether we cover them or not.


Questions? Just call us at 1-855-232-3596 (TTY: 711).

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