Medical Prior Authorizations

Prior Authorization Rules for Medical Benefits

What is Prior Authorization?

Prior Authorization is a decision made by your health plan regarding certain medical services that require approval before they are provided. You, your representative, or your network Primary Care Provider (PCP), or the provider who intends to furnish the services, may request a Prior Authorization.

This process is sometimes referred to as a referral request. A referral means your network PCP must approve before you can see another provider. If you do not get a referral, your plan may not cover the service.

Referrals are NOT needed for:

Emergency a Taripato
Dagdagus nga kasapulan nga taripato
Kidney dialysis services at a Medicare-certified dialysis facility when you are outside the plan’s service area
Women’s health specialist visits
Services from Indian health providers (if eligible)

What Services Require Prior Authorization?

To obtain a list of services that require prior authorization, please contact Member Services or refer to your Evidence of Coverage.

How to Request Prior Authorization

You may request prior authorization by contacting Member Services. Providers are encouraged to submit requests through the Secure Provider Portal, by phone, or by fax.

Decision Timeframes

Please refer to your Evidence of Coverage or contact Member Services for further information.

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Authorization determinations are made based on medical necessity and appropriateness and reflect the application of the plan’s review criteria guidelines.

Your plan will expedite a decision if waiting for a standard determination could jeopardize your health, life, or ability to regain maximum function.

Important: Prior authorization is not a guarantee of payment. Your plan retains the right to review medical necessity, eligibility, and benefit limitations after services are received.

Pharmacy Prior Authorization

To learn more about drug coverage determinations, redeterminations, and prior authorizations, use the Find Your Plan tool to locate your plan, then select “Pharmacy” from the right sidebar.