See If You Need Prior Authorization
To begin your search, enter your Member ID and the procedure code or service description.
What’s Prior Authorization?
Before you get some medical treatments, your provider might have to tell your insurance company about them. This is called “prior authorization.” You might hear it called “pre-certification” or “pre-authorization.” Either way, this step is like asking permission in advance to double-check that:
- The treatment is safe and helpful for you, based on medical knowledge.
- There aren’t any mix-ups with the billing, so you won’t get a surprise bill from the provider.
It’s a team effort between your provider – such as your doctor – and insurance company to make sure you get the best care without surprises.
Making Prior Authorizations Easier, Faster
We’ve created the Prior Authorization Search tool to make the process easier. This tool can be used by you or your provider. You only need two things to use the tool:
- Your member ID number on your insurance card
- The procedure code or service description from your provider
Watch the video to learn more about using the search tool.
What You Can Do to Help with Prior Authorizations
Plan Ahead
Talk to your provider about checking treatment options early. Standard requests can take up to 15 days to review. It can take up to 72 hours for urgent requests.
Be Proactive
Be sure to update your provider if you change insurance companies or insurance plans. This helps them know when they need to make a request.
Stay Involved
It’s a good idea to keep talking to your provider and insurance company about a prior authorization request. Your involvement is important.
Be Curious
Using the search tool, you can look up treatments on your own or with your care provider. This helps you see if your provider might need to submit a request before your next visit.
When Prior Authorizations are Needed
Only about one percent of the 68,000 medical service codes need prior authorization. That means it’s more likely that your treatment will not need a request. Below are some of the most common treatments that might require one.
- Advanced radiology imaging (PET scans, however, no longer require prior authorization)
- Certain medicines including injectables and intravenous therapies
- Prosthetic supplies
- Heart-related treatments, including surgery, advanced imaging, diagnostics and implants
- Muscle and bone treatments, including spinal injections for pain management, surgery and fusions
- Cancer treatment and medications
- Molecular lab tests
- Sleep treatments, supplies and testing
- Radiation-related treatments and procedures
- Transplant services
- Some surgical procedures
- Some behavioral treatments, such as residential treatment centers
- Some medical equipment and devices, including wheelchairs
- Some services might require a request to continue receiving the service after a set number of visits
Code | Description | Prior Authorization Status |
V5095 | Semi-implantable middle ear hearing prosthesis | PA Required |
T1030 | Nursing care, in the home, by registered nurse | PA Required |
Above: How a medical service code might look with a description and if it requires prior authorization.
How Prior Authorization Requests Get Reviewed
If a treatment needs this double-check, the process is simple. First, your provider sends a request to your insurance company. Next, the insurance company reviews the request. This is to ensure the treatment is covered by your plan and medically necessary.
What’s Reviewed in a Request
When a request comes in, we need to review that the treatment your provider is recommending is covered by your plan and medically necessary. But what does that mean, exactly? To be considered medically necessary, the treatment needs to pass a few tests:
- Needs to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms
- Meets accepted medical standards and consider the symptoms and side effects.
- Fits the policy tied to your medical plan
To find what your plan covers, refer to your health plan information or call the number on the back of your insurance card.
