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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 family planning and emergencies.
Are you an American Indian (AI) or Alaska Native (AN)? If yes, you may get services from any Indian Health Care Provider (IHCP), even if they are out of network.
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. 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 1-844-365-4385 (TTY: 711). We’re here for you 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 medical director will review it next.
- 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. 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 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 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 1-844-365-4385 (TTY: 711). We’re here for you 24 hours a day, 7 days a week.