Medical necessity and prior authorization timeframes and enrollee responsibilities- Dean - WI

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Understanding Prior Authorization

As you navigate your health care, it’s important to note there are certain medical services or provider visits that will require prior authorization by Dean Health Plan. The process below will help walk you through whether you need a prior authorization.

Dean Health Plan requires these authorizations so our Medical Affairs team can review the medical necessity of the recommended service or visit and make sure you are getting appropriate care. Medically urgent authorizations, as determined by your physician, are handled as a priority. A good rule to remember is that any time you seek services with an out-of-network or nonparticipating provider, you will need to obtain a prior authorization from an in-plan provider.

For services provided by an In-Network provider, your provider is responsible for obtaining prior authorization when required. For Out-of-Network providers, please be aware that you will be financially responsible for the full cost of any service for which prior authorization is required if you fail to obtain prior authorization in advance of receiving care. Prior authorization requests should be submitted at least 15 business days prior to your planned procedure. 

Is it covered? Keep in mind, a prior authorization can only be obtained for services that are covered under your plan benefits.

For example, if bariatric surgery is an exclusion of your policy, a prior authorization will not change that benefit. If the services are covered under your plan, they are also still subject to any applicable cost sharing (i.e. copays, co-insurance or deductibles).

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