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Prior Authorizations

Helping you get the right care in the right place at the right time.

Sometimes known as “precertification” or “preauthorization,” prior authorization is a process for collecting information before you receive select procedures, services and supplies (and even prescription drugs) requested by your doctor.

Procedures and services on the Prior Authorization List related to your policy may require notification and/or a coverage determination:

  • Notification is a data-entry process that does not require judgment or interpretation for benefits coverage.
  • A coverage determination is based upon plan documents and, when applicable, a review of clinical information to determine whether clinical guidelines/criteria for coverage are met.

For example, your doctor may determine you need an inpatient hospital admission to care for a certain condition, illness or injury. Before being admitted to the hospital, you or your doctor should get prior authorization.

Please note: Prior authorization is not a promise your policy with cover all of the cost. Also, prior authorization is not required in the case of an emergency.

Your Schedule of Benefits and your Certificate of Coverage/Insurance describe the level of coverage available under your policy. When seeking services from a non-participating provider, please refer to the section of your Certificate of Coverage/Insurance that describes the process for obtaining prior authorization. Need to view your policy documents? Log in or register for My Online Services today.

Need to get prior authorization? Call Customer Service at the number on your member ID card or contact us.

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