3. Prior Authorization

Prior authorization

Understanding prior authorization

Medical necessity + enrollee responsibilities

As you navigate your health care, it’s important to note that certain medical services or provider visits require prior authorization.

A prior authorization is a written request submitted by your network PCP or network specialist provider. It seeks our approval for you to receive services from another in-network, or sometimes out-of-network, provider.

If you receive services without an approved prior authorization request, the claim may be denied if it is not found eligible for coverage. You may be financially responsible for the full cost of any service or drug for which prior authorization was not approved when required.

The process below will help walk you through whether you need a prior authorization. Services provided in an emergency room do not require a prior authorization. 

Why?

Certain services may require prior authorization before benefit coverage and claims payment can be provided. If a service isn't urgent, the prior authorization request must be submitted and decided by us before you receive this service.

We require these authorizations so our utilization management team can review the medical necessity of the recommended service or visit and make sure you are getting appropriate care.

Medical necessity means that the treatment, services, or supplies provided are: 

  • Consistent with the illness or injury
  • Follow generally accepted standards of medical practice
  • Not solely for the convenience of a member, hospital, or other provider 
  • The most appropriate supply or level of service that can be safely provided to you in the most cost-effective manner

Is it covered?

Keep in mind, a prior authorization doesn't change the benefits under your plan. If a service is an exclusion of your plan, a prior authorization will not change the fact that the service isn't a covered benefit. 

If the services are covered under your plan, and you have an approved prior authorization, the services are subject to any applicable cost sharing (i.e. copays, co-insurance, or deductibles).

If your request for services is denied, you'll always be notified in writing. Your provider and you make the final decision about whether you will receive any services. To find out if a service or procedure is a covered benefit under your plan:


Getting prior authorization

Some medical services require approval before you receive the service. Our prior authorization process helps ensure you receive medically necessary care at the right time with the right provider. Your plan provider should submit prior authorization requests as early as possible and prior to your scheduled services to ensure a determination can be made prior to their receipt. 

  Out-of-network physician or specialist

If your provider recommends you see someone outside our network, you may need a prior authorization before your visit. If so, your in-network provider must submit a prior authorization request. We'll send you our determination by mail, or you can contact Member Services to check on the status of the request.

We recommend that you wait for a determination about your request before receiving services with an out-of-network provider. Be aware that you will be financially responsible for the full cost of any service with an out-of-network provider if the authorization your provider has submitted is denied.

Medical procedure or service

If your provider recommends you receive a procedure or medical service, a prior authorization may be required. If so, your provider is responsible for obtaining the approval before providing the procedure or service.

Some plans allow you to see an out-of-network provider. For these plans, if your provider fails to obtain a prior authorization, you may incur a financial penalty in addition to any applicable cost share.

Steps to take

Your provider will help you coordinate the care you need. All plan providers have someone who works on acquiring authorizations for their patients.

To find out if a service or procedure requires a prior authorization:


When we receive a request from your provider, if it is prior to the service being provided (prior authorization), the determination is made within 72 hours of receiving an urgent request or within 15 calendar days of receiving a non-urgent request. If the request is received while you are receiving a service, such as an inpatient admission (urgent concurrent request), the determination is made within 24 hours or as soon as the necessary medical information is received, but will not exceed 72 hours. If the request is received after the service has been completed (post-service), the determination is made within 30 calendar days. Remember, even with a prior authorization, not all services are covered at 100%. You will be responsible for the co-pays and deductibles outlined in your member certificate.


Service examples

See our list of services that need approval. This is not a comprehensive list. Be sure to check with our Member Services for details about what needs prior authorization.