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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.

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Just call us at 1-833-711-0773 (TTY: 711).We’re here for you 24 hours a day, 7 days a week.

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. We’ll work together to make sure the service is what you need.


Before the date you get care, you’ll need PA for these services:


  • Inpatient care in a hospital
  • Intensive home-based treatment
  • Partial hospitalization for substance use disorder
  • Partial hospitalization for a mental health disorder
  • Care in a psychiatric residential treatment facility  
  • Services from a non-participating provider (except emergency services)


This list doesn’t include all services that need PA. For more information, call us at 1-833-711-0773 (TTY: 711).


You need PA for all out-of-network services, except for 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 a service needs PA before they provide it. They can get the full list of services on their Provider Portal.

How we conduct medical reviews

We only cover behavioral health services if they are medically necessary. When we receive a PA, we use certain medical review criteria to make decisions about medical necessity. The medical review criteria we use includes:


  • Criteria required by applicable state or federal regulatory agencies
  • Aetna® Medicaid Pharmacy Guidelines
  • Milliman Care Guidelines (MCG)  
  • American Society of Addiction Medicine (ASAM) – substance use disorder services
  • Aetna Clinical Policy Bulletins (CPBs) on
  • Aetna Clinical Policy Council Review

For a copy of our review criteria, you can call 1-833-711-0773 (TTY: 711). Representatives are available from 7 a.m. to 8 p.m. Monday through Friday. 

How PA works

How PA works

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


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

  •  A health plan clinician will review the information.

  • If they can’t approve the request, a health plan Medical Director will review the information.

  • Your provider can discuss the determination with the health plan Medical Director.
  • You and your provider will get a letter with our determination and whether the request has been approved, denied, or partially denied. We also send a letter to you and your provider if we are extending the time to complete a review of a PA request.
  • 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 time, before you get it.


UM is the process we use to make sure you get covered quality services that are medically necessary. We also 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

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 and whether we cover them or not.


You can get the most current list of treatment options, too. Just check your member handbook on our member materials and forms page. Or call us at 1-833-711-0773 (TTY: 711). Representatives are available from 7 a.m. to 8 p.m. Monday through Friday. 

* We will provide 30-calendar days advance notice of changes to the list of all services requiring prior authorization. 

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