Prior authorization

Senior physician smiling at a senior woman in a hospitalUnderstanding prior authorization

Medical necessity and enrollee responsibilities

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

A prior authorization is a written request your network PCP or network specialist provider completes requesting authorization or approval for a specific service or services with a network provider or, in some cases, an 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 requested 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. 

Question mark iconWhy?

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.

Dean Health Plan requires 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

icon of a piece of paper with check marks on itIs 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 by Dean Health Plan 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. 

Map of the United States icon  Out-of-network physician or specialist

If your Dean provider is recommending you see a physician or specialist outside of the Dean Health Plan network, your plan might require you have an approved authorization before your visit. If your plan requires a prior authorization to see an out-of-network provider, your Dean provider must submit a prior authorization request for review. You’ll receive our determination by mail or you can call our Customer Care Center to check on the status of the prior authorization. 

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.

Tablet iconMedical procedure or service

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

Some plans allow you to see a provider outside the Dean Health Plan network. 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 prior authorization request from your provider, we typically decide on requests for prior authorization for medical services within 72 hours of receiving an urgent request or within 15 calendar days for non-urgent requests. 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 Customer Care Center for details about what needs prior authorization.