How It Works
As the provider, you are responsible for submitting preauthorization requests to us for approval. Members do not request preauthorization. To submit a preauthorization request:
- Check the preauthorization tools on our website for specific types of drugs, medical procedures and imaging services.
- Complete the necessary form(s) and gather documentation. If there’s a designated form, use that – otherwise refer to the general Preauthorization Request Form (pdf)
- Submit the appropriate form and documentation to us via fax at 800-269-8561.
What happens if preauthorization isn't received for medical care?
If a member’s medical care or procedure fails to receive a required preauthorization, the member will be responsible for paying the entire billed charge.
What happens at the pharmacy?
- The pharmacist enters the member’s prescription information into the claims system.
- If a drug requires preauthorization, the pharmacist will receive a message that a preauthorization is required. In most cases, the pharmacy will notify you as the provider about this requirement.
- As a provider, you need to fax 800-269-8561 or send a secure email to Pharmacy@AveraHealthPlans.com with the supporting documentation for Avera Health Plans to begin the preauthorization process. (This may take up to 72 hours to complete.)
If the preauthorization is approved: The pharmacy will be able to process the prescription for the appropriate co-pay (if applicable).
If the preauthorization is denied: As a provider, you will need to contact the member to determine alternate options.
Medical and Imaging Services
Need to check if preauthorization is needed for certain medical care or procedures – or for imaging services?
- Enter the complete 6-digit group number from our member ID cards that begin with a 99, and for our new member ID cards, the “A” followed by a 7-digit number. (For UMR, enter the 9-digit with no dash or space).
- Review the results, which will display services requiring preauthorization and what’s not covered. You’ll also find related preauthorization forms and instructions to submit to us.