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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, 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 have a list on their Provider Portal. And you can see a list of services that need PA (PDF) here.

How PA works

How PA works

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

 

  • Your provider will call us about the service or supply they think you need. (This should happen at least 3 working days before you get it.)
  • We review the info from your provider. We may ask to see their written notes about why you need this care.
  • Your provider will get a notice when we approve or deny a service.
  • If we can’t approve the request, we send it to one of our health plan providers to review.
  • If we deny your request, you and your provider will get a letter explaining why.
  • 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 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 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.

Need more info? 

 

Here’s how to get in touch with our UM team:

 

  • Call 1-888-348-2922 (TTY: 711), Monday through Friday, 8:30 AM to 5 PM, to reach the UM department.
  • Leave a voice mail message. Just call Member Services anytime to leave a message and we’ll return your call.

 

Members of the UM team will let you know their name, title and why they’re calling when they call you back.