Prior Authorization (PAs)
Sometimes your PCP, or another provider, may need to ask us to approve care before you get a service or prescription. This is called “prior authorization.” Your PCP or provider will contact us for this approval.
Prior authorization is needed for these types of services:
- Medical supplies and equipment
- For rented and purchased medical supplies and equipment, only those costing more than $750 need approval
- Some medical tests done by your PCP or provider
- Cardiac programs
- Home health care
- Therapies (physical, occupational, speech)
- Inpatient, including surgical procedures, certain behavioral health outpatient services, and residential behavioral health services.
If we do not approve a prior authorization request, we’ll let you know. If we do not approve a request, and you still receive the service, the provider cannot bill you unless you agreed to pay for it in writing. If prior authorization is denied, you can ask for an appeal. If you still are not happy once the appeal is complete, you can ask for a State Fair Hearing.