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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 prior authorization for all out-of-network services, except for family planning and emergencies. If you don’t get it, you may have to pay for services that:
You get from an out-of-network provider
Need prior authorization
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 1-800-822-2447 (TTY: 711). We’re here for you Monday through Friday, 8 AM to 5 PM.
How prior authorization works
How prior authorization works
Your provider will submit your prior authorization request. 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 our nurse can’t approve the request based on our criteria, a medical director will review it to make the final decision.
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.
Prior authorization timelines
Once your doctor has submitted a prior authorization request, you should get an answer within 14 days. More urgent requests may take less time. Here are those timelines:
Emergency and urgent hospital admissions – Immediate
Urgently needed medications or services – 24 hours
Home health services – 48 hours
If we don’t get the info we need for your PA request in 14 days, we’ll ask your provider for it. We’ll do this by sending them a written notice. Your provider then has 14 more days to get us that info. Once we get it, we’ll make a decision about the request within 2 business days.
Right care, right place, right time
Right care, right place, right time
Prior authorization 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
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 1-800-822-2447 (TTY: 711).