Preauthorization

Preauthorization 

Providers: Download the Preauthorization/Prior-Auth Request Form

To help contain costs and ensure that the services paid for by your health plan are medically necessary and appropriate, some services require our authorization before you receive them. Failure to receive our preauthorization for the services listed below could result in coverage for the service being denied. If we do cover a service for which preauthorization was required but not obtained, the member or provider could be responsible for a penalty of 50% of the cost of the service, up to $500. 

Hospital Admission Notification

All our health plans require you notify us before you have an inpatient stay for medical and behavioral health care.

Planned Hospital Admissions

If you or anyone in your family is expected to stay overnight in a hospital, call us at 800.279.4000 before you're admitted.
You will want to call at least five days in advance whenever possible to keep everything running smoothly. Since this notification is a plan requirement, your reimbursement for services may be reduced unless you notify us.  Please check your policy for specific notification requirements for maternity-related admissions and emergencies.

Emergency Hospital Admissions

If you are admitted to the hospital for an emergency, notify us within 72 hours following the emergency.

Services Requiring Preauthorization include, but are not limited to the following:

• Behavioral Health Higher Levels of Care
  • Inpatient Services
  • All out-of-network services regardless of level of care
• Dialysis (outpatient and home dialysis)
• Durable Medical Equipment for the following items with a purchase OR rental price greater than $5,000
  • Compression Vests for Cystic Fibrosis
  • Electric Wheelchairs
  • Oral Appliances for Sleep Apnea
  • Prosthetics
• Genetic Testing
  • Exception: the following Genetic Testing Services DO NOT require Preauthorization:
    • CFTR/Cystic Fibrosis Transmembrane Conductance Regulator (81220)
    • Fetal Chromosomal Aneuploidy Genomic Sequence Analysis Panel (81420)
    • Fetal Chromosomal Microdeletion(s) Genomic Sequence Analysis (81422)
    • Fetal Aneuploidy DNA sequence Analysis (81507)
    • Fetal Congenital Abnormalities (81511)
    • Spinal Muscular Atrophy (SMA) Carrier Screening (81329)
• Hyperbaric Oxygen Therapy
• Inpatient admissions (elective/planned, including observation stays that extend beyond 48 hours)
• Intensity-Modulated Radiation Therapy (IMRT).
• Invasive Back Procedures (injections, radio frequency ablation)
• Nutritional Support (Enteral Feedings)
• Oncology Related Services:
  • All treatment regimens (including chemotherapy, radiation, services, procedures, etc. being requested for a member with a cancer diagnosis requires prior authorization. [Use this form when requesting authorization]
• Oral Appliances
  • All TMD/TMJ Oral Appliances
  • Sleep Apnea Oral Appliances over $5,000
• Orthognathic Surgery
• Orthopedic Procedures such as, but not limited to:
  • Arthroscopic Procedures (knees, hips and shoulders)
  • Back Surgeries
  • Total Joint Replacements/Revisions/Repairs
• Proton Beam Therapy
• Reconstructive or Plastic Surgery such as, but not limited to:
  • Abdominoplasty
  • Blepharoplasty and Ptosis Repair
  • Brachioplasty
  • Breast Augmentation, Lift, or Other Breast Reconstructive Surgery
  • Panniculectomy
  • Prophylactic Mastectomy
  • Septoplasty
  • Thighplasty
• Skilled Nursing Facilities
• Skilled Rehabilitation Services
• Sleep Studies - in a Facility (in-home sleep studies do not require preauthorization)
• Specialty Drugs (See Prescription Drug Preauthorization list at the top of the page)
• TMJ/TMD Devices/Oral Appliances
• Transplant evaluations, services, and procedures
• Varicose Vein Treament

Decisions on preauthorization requests submitted with all necessary clinical information will be made within 15 calendar days of receipt of the request. It is highly recommended you not schedule services prior to receiving an approved authorization.

Please note that the preauthorization of any procedure does not guarantee benefits or payment. Approval is based on medical appropriateness and necessity as defined in the patient’s benefit plan or certificate.

All benefits are subject to the term, conditions and exclusions of the benefit plan or certificate.