For some types of care, your primary care provider (PCP) or specialist will need to ask us for permission before you get the care. This is called asking for prior authorization, prior approval or pre-approval. It means that we must make sure that the care is medically necessary or needed.
Care is medically necessary if it is reasonable and necessary to protect your life, keeps you from becoming seriously ill or disabled, or alleviates severe pain. For emergency care, you never need prior authorization. Even out-of-network emergency care is covered. This includes having a baby.
The following always need prior authorization even if you get them from one of our network providers:
- Ask your primary care provider (PCP).
- A treatment can have multiple procedure codes. If you do not know the procedure code(s) or name(s) for the treatment you want, ask your provider.
Prior authorization is based on medical necessity and not a guarantee of coverage or eligibility.
Learn about when you need a referral for authorization and how long it takes to get authorization. View your Member Handbook
The process you use depends on the type of problem you have. Use one process for coverage decisions and appeals and another for making complaints (also called grievances).
To ensure fairness and promptness, each process has a set of rules, procedures, and deadlines that you and the plan must follow.
Please click here to file a grievance or appeal.
