Preauthorizations – How to Know If You Need Approval
In some circumstances, our approval (or preauthorization) is required before you receive a specific service, procedure, drug or medical supplies – in order for us to provide coverage.
If you fail to receive a required preauthorization, you’ll be responsible for paying the entire billed charge.
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Note that preauthorization does not guarantee benefits and the preauthorization list is subject to change. Benefits are subject to all conditions of your health insurance policy.
Preauthorization Process for Health Plan Members
- Your provider must check our provider resources for preauthorization requirements for medical procedures, imaging and prescription drugs. If a preauthorization is required, the provider must submit the appropriate preauthorization form and clinical documentation to us.
- Our clinical review team will review the request and a letter will be mailed to you and your provider with the approval or reason for denial within 15 calendar days.
- If approved, the letter will list which specific services, procedures and/or drugs have been approved. Please read the letter carefully so you know what services your provider has been authorized to perform.
Preauthorization Process for Medicare Supplement Insurance
- Standard Medicare Supplement Plans: You do not need a preauthorization to use any facility.
- Select Medicare Supplement Plans: You do not need a preauthorization if you use a facility listed in the Network Hospital Directory for Select Plans (pdf). If the facility is not listed in the directory, your physician will need to call for a preauthorization of services. This needs to be approved before you receive services at the out-of-network facility.
Our clinical team will respond in 24 hours if your situation is urgent – meaning that a delay could jeopardize your life, health or ability to regain maximum function or would cause severe pain that could not be adequately managed without the requested care or treatment.
- In the case that we are unavailable – such as on weekends, holidays or after business hours – your provider must contact us no later than two business days after you receive the services, supplies or procedures.
- Learn about emergency and urgent care coverage.
- Learn about your insurance when you travel.