Most covered services must be approved by your Care Manager before you get them. You may also need this to keep getting the service(s). This is called prior authorization. You or someone you trust can ask for this.
When you ask for prior authorization of a service, it is called a service authorization request. See your Care Plan for a list of services that are authorized.
You or your provider can request a service authorization by:
- Contacting your Care Manager
- Faxing a request to your Care Manager at 1-866-287-3291
- Sending a request in writing to:
Services will be approved by the timeframes below. We will approve them for a certain amount of time. This is called an authorization period.
During an authorization period, you or your provider might ask us to approve more of a service you are getting. If this happens, we will re-evaluate your care. This is called a concurrent authorization.
What Happens After We Get Your Service Authorization Request?
The health plan has a review team to be sure you get the services we promise. Doctors and nurses are on the review team. Their job is to be sure the service you asked for is medically needed and right for you. They do this by checking your treatment plan against medical standards.
Any decision to deny a service authorization request or to approve it for an amount that is less than requested is called an action. These decisions will be made by a qualified health care professional. If we decide that the requested service is not medically necessary, the decision will be made by a clinical peer reviewer. This may be a doctor, or a health care professional who usually provides the care you ask for. You can ask for the medical standards, used to decide medical necessity.
After we get your request we will review it under a standard or fast track process. You or your doctor can ask for a fast track review if it is believed that a delay will seriously harm your health. If a fast track review is denied, we will handle your case as a standard review. You may be in the hospital or leaving the hospital and we get a request for home health care, we will handle it as a fast track review. In all cases, we will review your request as fast as your condition requires, but no later than the timeframes below.
We will tell you and your provider both by phone and in writing if your request is approved or denied. We will also tell you the reason for the decision. We will explain what options for appeals or fair hearings you will have if you don’t agree with our decision.
Timeframes for Prior Authorization
- Standard Review: We will make a decision about your request within 3 work days of when we have all the information we need. If we need more information, we’ll let you know no later than 14 days after we get your request.
- Fast Track Review: We will make a decision and you will hear from us within 3 work days. We will tell you by the third work day if we need more information.
Timeframes for Concurrent Authorization
- Standard Review: We will make a decision within 1 work day of when we have all the information we need. If we need more information, we’ll let you know no later than 14 days after we got your request.
- Fast Track Review: We will make a decision within 1 work day of when we have all the information we need. You will hear from us no later than 3 work days after we get your request.
If you are in the hospital or have just left the hospital, and you ask for home health care on a Friday or day before a holiday, we will make a decision no later than 72 hours from we have all the information we need.
In all cases, you will hear from us no later than 3 work days after we got your request. We will tell you by the third work day if we need more information.
If we need more information to make either a standard or fast track decision about your service request we will:
- Write and tell you what information is needed. If your request is in a fast track review, we will call you right away. We will send a written notice later.
- Tell you why the delay is in your best interest.
- Make a decision no later than 14 days from the day we asked for more information.
You, your provider, or someone you trust may also ask us to take more time to make a decision. This may be because you have more information to give the plan to help decide your case. You can write to us or call 1-866-661-1232.
You may not agree with our decision to take more time to review your request. If so, you or someone you trust can also file a complaint with the plan. You or someone you trust can also file a grievance about the review time.
We will let you know by the date our time for review has expired. If you do not hear from us by that date, it is the same as if we denied your service request. If you are not pleased with this answer, you have the right to file an action appeal with us.
See the Action Appeal section in your member handbook.