The best way to find out if your coverage requires preauthorization is to look on your health plan ID card. If preauthorization is required it will be listed along with a toll-free number to our Utilization Review Manager. You may also call the toll-free customer service telephone number listed on your ID card to see if preauthorization is required.

Preauthorization is easy. Just call the toll free number listed on the back of your identification card to speak to a Utilization Review Manager team member. Please be sure that you have the following information:

1. Insured's name and identification number.
2. Insured patient's name, birth date, address and phone number.
3. The physician's name, address, and phone number.
4. Name, address and phone number where care is to be received.
5. Proposed date and reason for service and/or treatment.
6. Diagnosis and/or procedure codes for the requested services.

Preauthorization does not guarantee that benefits will be paid. Payment of benefits is subject to the terms and conditions set forth within the policy/certificate, including out of network provisions. The member is responsible for any deductible, coinsurance or copayment described in the policy/certificate. Refer to your health insurance policy for benefit information or call a customer service representative at the toll-free number listed on the back of your health plan ID card.

Preauthorization should be obtained at least 3 days prior to receiving the medical service or planned admission to the hospital. In the event of an emergency admission to the hospital, a call needs to be made within 24 hours or when reasonably possible. If the admission occurs on a weekend or holiday a call should be placed on the next business day.

If your coverage requires preauthorization, your benefits will be reduced if you do not obtain preauthorization for medical services that require authorization.

Medical necessity determines if the medical services being provided are:

• Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness, injury or disease.
• In accordance with the generally accepted standards of medical practice.
• Not for the convenience of the patient, physician, or other providers.

Please note: Medical necessity is not a determination of benefits or guarantee that benefits will be paid Payment of benefits is subject to the terms and conditions set forth within the policy/certificate, including out of network provisions. The member is responsible for any deductible, coinsurance or copayment described in the policy/certificate. Refer to your health insurance policy for benefit information or call a customer service representative at the toll-free number listed on the back of your health plan ID card.

Preauthorization is the process of determining the medical necessity of your hospitalization, surgery or requested medical service. Our Utilization Review Manager works in partnership with your medical provider to ensure you get the appropriate care in the appropriate setting for your medical condition.

In most cases, your medical provider will take care of the preauthorization. However, you are still responsible for ensuring that your care is preauthorized. Benefits may be reduced for failing to obtain preauthorization when required. So always verify with your physician or hospital that they have contacted us.

Depending on your coverage, preauthorization may be required for:

• Inpatient Hospitalizations
• Certain Surgeries
• Home Health Care
• Home Infusion Therapy
• Hospice care
• Outpatient Physical, Occupational and Speech Therapy
• Certain Prescription Medications <link to the Preauthorization Pharmacy section>

To verify if a medical service requires preauthorization call the toll free customer service telephone number listed on your ID card.