Skip to main content

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 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 PA for most out-of-network services, except for things like family planning and 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 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.

 

Materials and forms


You can also get a copy of our review criteria. Just contact us to learn more. 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 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.

PA timelines

 

Allow us at least three business days for a response. We handle urgent requests for medically non-urgent services in the same time frame as a routine request. Just contact us with any questions.

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 about prior authorizations?

 

Medicaid/FAMIS: Call our Health Services Department at 1-800-279-1878. You can get help 24 hours a day, 7 days a week. For after-hours or weekend questions, just choose the prior authorization option to leave a voicemail. We’ll return your call. 

 

CCC Plus members: Call 1-855-652-8249 for PA questions.