Prior Authorization
You may need to get approval before you get certain services from in-network providers. This is called prior authorization. It’s an evaluation of a proposed service to determine if it’s medically necessary and appropriate based on your health care needs.
Benefits of prior authorization:
- Improves the overall quality of care
- Ensures you are receiving the right care at the right time
- Identifies members who are appropriate for care management
Your provider is responsible for getting prior authorization from the plan for certain services when seeking care in-network.
Examples of services that require prior authorization:
- Hospital admissions
- Outpatient surgeries
- Complex imaging: MRI, CT, and PET scans
- Outpatient therapies
- Pain management
For a complete list of services that require prior authorization, see your Evidence of Coverage (EOC).
Covered services that need prior authorization are marked in the Medical Benefits Chart in Chapter 4 in the Evidence of Coverage (EOC).
Out-of-Network Services
In a PPO, you do not need prior authorization to obtain out-of-network services. However, we recommend you call Member Services before obtaining services from out-of-network providers to confirm that the service is covered and medically necessary. Members may be liable for out-of-network services charged if the service isn’t medically necessary or service isn’t covered.
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