Do I need approval before having a service or procedure done?

In some cases, yes. We require a preauthorization when specific services, supplies and procedures must be approved by us before the services are received.

It's especially important that the services are done with an in-network provider.

Contact our Service Center if you have any questions:
1-888-322-2115
Ask@AveraHealthPlans.com
Mon-Fri: 8 a.m. - 5 p.m. CT

Preauthorization Process for Medical Services

Note: Preauthorization does not guarantee benefits. The preauthorization list is subject to change.

To help ensure that our members receive quality health care in an appropriate treatment setting, our utilization management program uses medical necessity guidelines in evaluating requests for coverage.

We use the following preauthorization process:

  • Your provider must call or fax us if you need services requiring preauthorization.
  • Our medical management team will review the request and a letter will be mailed to you and your provider with the approval or reason for denial. This process is completed within 15 calendar days.
  • For approved services, the letter will list the services that have been approved (for example, office visit only or office visit and lab tests). Please read the letter carefully so you know what services your provider has been authorized to perform.

Our chief medical officer is available to discuss coverage determinations based on medical necessity. Utilization management decision-making is based on medical necessity, applicable coverage guidelines, and appropriateness of care and service.

Note: We do not reward individuals who conduct utilization review for issuing denials of coverage, nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. Financial incentives for utilization review do not encourage decisions that result in under-utilization.