Medical pre-authorization

Some medical procedures require pre-authorization before you receive treatment in order to get coverage from your health plan.

Pre-authorization allows us to review your treatment within the context of any other health issues you may have and to consider the latest scientific research available to manage your condition. Some conditions have a wide range of treatment choices, and some treatments work better than others. Checking in on your progress after a series of treatments helps us make sure your treatment is effective, medically necessary and right for you.

Pre-authorization helps you:

• Understand your treatment options and any related risks
• Ensure that you'll have insurance coverage for a procedure, treatment or service
• Avoid inappropriate or unnecessary medical treatment
  Save unnecessary out-of-pocket costs by guiding you to the approved service or vendor
  

Your doctor should know which procedures require pre-authorization. If a doctor does not get pre-authorization before treating you, your health plan will not cover those costs and the doctor may bill you for that treatment.

Doctors may contact our clinical partner to get pre-authorization online, by fax or by phone. If they seek pre-authorization online, they get an immediate response. They can also get pre-authorization before you arrive for your scheduled service or procedure to avoid delay.

If you use an in-network doctor, you don't need to do anything. Our clinical partner evaluates your treatment plan to make sure it is the most effective treatment based on published research. Our partner also ensures that it is medically necessary and covered by your health plan.

If you use an out-of-network doctor, contact us about your options. Using an out-of-network doctor may mean higher out-of-pocket costs for you.

Treatment, services and equipment that may require pre-authorization:

• Some surgeries and reconstructive surgery
• Planned admission into hospitals or skilled nursing facilities
• Transplant and donor services
• Specialized imaging such as MRIs, CT scans and cardiac imaging
• Non-emergency air ambulance transport
• Prosthetics and some orthotics
• Home medical equipment
• Interventional pain procedures
• Physical medicine services such as physical therapy and chiropractic care

• Sleep studies

Prescription medications that may require pre-authorization:

• Some high-cost injectable medications
• Specialty drugs

If you request a service or item you expect to be non-covered (including those that are statutorily excluded by Medicare, or non-covered by your Medicare Advantage plan), please follow our Medicare pre-authorization process to request a pre-service organization determination. You must follow these guidelines for a pre-service organization determination for services to be considered for approval.

Within 14 calendar days, we will approve or deny the request, and provide notification to you and your provider. A denial notice will include the reason and explain the appeal process.