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 prior authorization or pre-service review is required, log in to our prior authorization tool for member-specific information. For general code information, use our code check tool.
Submit a request using our prior auth tool.
What you'll need to complete a prior auth request:
The tool considers the member's eligibility, coordination of benefits, and whether the plan requires authorization for the requested services. Attaching supporting documentation is required. You’ll get a reference ID number on the confirmation page.
You can also fax a request form to 800-843-1114. Be sure to include supporting documentation (see code list for details).
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.
If you have any technical issues with the tool, call 800-722-9780 or email the issue to firstname.lastname@example.org
Visit AIM Specialty Health or call 866-666-0776.
Visit eviCore healthcare.
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.