Prior authorization for requested services

Prior Authorization and Notification

• Prior authorization is required for certain medical pharmacy and retail pharmacy drugs.
• Prior authorization is not required for inpatient or outpatient medical services.
• Notification is required for inpatient admission, changes, and discharges. These notifications help us to better serve our members, and they will also expedite the process of claims being paid correctly and in a timely manner. Notifications allow for the member to be followed through discharge, and upon discharge, to determine if a referral to Case Management is needed to provide members with assistance and access to available resources (which also helps to reduce the members’ risk of readmission).

Organizational Determination/Benefit Inquiry (ODBI)

Although prior authorizations for inpatient and outpatient medical services are not required, providers may voluntarily request a pre-service review of a proposed service, procedure, pharmacy medication, medical trial, or other services/items for assessment of plan benefit coverage. ODBIs help members and providers make decisions about care options. Please include all relevant medical records and/or treatment plans.

Links to Forms

Please fill out the form in its entirety and include all relevant clinical documentation to support the request

Authorization, Notification & ODBI Form: Authorization | Organizational Determination Request Form

Pharmacy PA Form: Prior Authorization Form for Prescription Drugs

Post Service Review

Although most services do not require prior authorization, the service may still undergo a post-service utilization management (UM) review. These reviews apply to services after they have occurred. Post-service claims for covered services may be pended for review to determine whether the service or drug was covered under the member’s benefit plan, medically necessary and/or submitted for the appropriate level of care (note: a pre-service ODBI can be requested as a pre-service courtesy review). Please note, additional medical records or documentation may be required and requested to complete the review.

Guidelines and Policies Used for Utilization Review

During utilization review, we ensure the service is a covered benefit for the member and is not a plan exclusion. We consult the coverage policy and follow InterQual clinical criteria.

The InterQual® guidelines are used by our utilization management team to help assess whether a given medical condition and known or represented circumstances of a case support medical service(s) as the most appropriate treatment, or whether the medical condition/circumstances presented could be appropriately addressed with an alternative treatment. Use the self-registration tool at the link to create a login and view the criteria. Individuals without an email address should contact the plan to receive the criteria information via mail.