Many services require review before they are provided. Whenever possible, submit a review request before providing the service. This helps us pay claims faster with no unexpected cost to you or the member after the services are provided.
Sometimes a service requires prior authorization. If you don't get a prior authorization, it could result in a payment penalty for you or the member. Please note that you can't submit a prior authorization request by phone.
When a service requires pre-service review, there isn't a penalty, but we'll hold the claim and ask for medical records.
To see if we require a prior authorization or a pre-service review, use our code check tool.
Or, you can find member-specific information by logging in to our prior auth tool.
Note: The tool does not work with durable medical equipment (DME) or non-specific/unlisted codes.
Submit a request using our prior auth tool. (You'll need the member ID.) It takes into account the member's eligibility, their coordination of benefits, and whether or not their plan requires authorization for the requested services. You can attach records online and get an instant reference number.
Log in to get the status of a request by member ID or reference ID. Information is available to the ordering provider, servicing provider, and facility listed on the request (by TIN).
Note: We typically respond to your original request within 5 business days. It may take up to 15 days if we need additional information. As soon as we make a decision, we'll fax it to you. If we deny the request, we'll mail a detailed letter to you and the member.
You can change a review request by fax at 800-843-1114. Be sure to include the reference ID number.
Visit AIM Specialty Health or call 866-666-0776.
Visit eviCore healthcare.
For durable medical equipment, provider-administered infusion drugs, non-specific/unlisted codes, and requests with more than 10 procedure codes, fax your request to 800-843-1114. Be sure to use the appropriate form:
View prior auth details for admission and discharge notification.
We require review for major procedures or services that could be a health and safety issue for our members. This includes most planned inpatient services, some planned outpatient services, some durable medical equipment, and some in-office pharmacy services including injectables, IVs, and biologics.
Some common services that require prior authorization include:
Use our Rx search tool to see if a drug requires prior authorization.
If an emergency prevents you from getting prior authorization, you must notify us within 48 hours following onset of treatment, or as soon as is reasonably possible.
We know situations arise that may make it impossible for you to get prior authorization before treating a patient, or to notify us within 24 hours of admission. In these situations, please contact us before submitting a claim.