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

• Advanced imaging scans (e.g. MRI, CT scans) of the neck and spine provided on an outpatient basis. Such scans provided while you are inpatient or provided as part of emergency care are not subject to preauthorization. 
• Arthroscopic Procedures (Knees, Hips, and Shoulders)
• Autologous Chondrocye Implantations 
• Behavioral Health Higher Level of Care
• Partial hospitalization
• Intensive outpatient
• Residential services
• PET Scans 
• MRA Scans 
• Back surgeries for pain
• Continuous glucose monitors
• Dialysis (outpatient and home dialysis) 
• Invasive Back Procedures 
• Intensity-Modulated Radiation Therapy (IMRT).   *changes effective 4/1/2019
• Durable medical equipment with a purchase OR rental price greater than $1,000
• Cochlear Implants
• Elective and/or planned inpatient stays prior to admission 
• Electroconvulsive Therapy 
• Gastric Neurostimulators 
• Genetic testing
• Home Health Services – Including Wound Care 
• Hyperbaric Oxygen Therapy 
• Impression and Customer Preparation; Speech Aid Prosthesis
• Inpatient and outpatient facility usage associated with any dental services
• Insulin Pumps
• Knee Scooters 
• LINX
• Minimally Invasive Direct Coronary Bypass Grafts 
  
• Nuclear Medicine – Cardiology (Myocardial Perfusion Imaging, Tomographic/Planar) 
• Nonsegmental pneumatic appliance
• Oncology Related Services:

  • WEA will review all oncology related treatment plans for medical concordance

• Orthognathic Procedures   *these are still not covered for WEA Trust members in the State Health plan
• Osteochondral Autograft Knee, Open
• Outpatient Hysterectomy   *changes effective 4/1/2019
• Physical, speech, and occupational therapy services (excluding evaluations)
• Pneumatic Compressor
• Proton Beam Therapy   *changes effective 4/1/2019
• Psychological and neuropsychological testing [Use this form when requesting authorization]
• 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
  • Thighplasty
  • Treatment of varicose veins
• Segmental pneumatic appliance
• Skilled nursing facility care 
• Skilled rehabilitation services
• Sleep Studies
• Surgical Sleep Disorder Treatment 
• Specialty drugs and high-cost drugs with unique monitoring or delivery needs
• Tens Unit
• Total Joint Replacement  
• Transmagnetic Stimulation
• Transplant evaluations, services, and procedures 
• Treatment of temporomandibular disorders (TMD)
• UAS Therapy
• Ultrasound Elastography 
• Whole Body Imaging