Medical prior authorization guide for members
Our job as your health plan is to make sure that you receive the right care at the right time and at the most affordable price.
Doctors estimate that more than 20 percent of medical care is unnecessary and studies show that overuse of testing and treatment can lead to worse outcomes.
Examples include patients who are exposed to radiation from unnecessary CT scans and X-rays and patients who have back surgery and end up in worse shape.
To prevent these and similar bad outcomes, we have partnered with Magellan RX Management and eviCore healthcare to conduct prior authorization reviews for specific medical and pharmacy services.
What services require prior authorization?
Some of the most common medical services that require prior authorization approval are:
- Joint or spine surgery and pain injections
- Advanced imaging such as computerized tomography (CT scans), magnetic resonance imaging (MRI) and select cardiology testing
- Admission to the hospital, long-term care, skilled nursing and rehabilitation facilities
- Certain mental health services including non-emergency inpatient treatment
- Physical therapy, occupational therapy and speech therapy
- Chiropractic care, massage, acupuncture and other alternative care
- Specialty drugs including injectables for asthma, autoimmune disorders, and multiple sclerosis
To view the complete list of services requiring prior authorization for:
-
Medicare Members
Procedures and services requiring prior authorization for Medicare members -
Group/Individual Members
Procedures and services requiring prior authorization for Group/Individual plan members
Multnomah County Members
Who’s responsible for getting prior authorization approval?
It is your provider’s responsibility to obtain authorization before they provide treatment.
If you are seeing in-network providers, they are financially responsible if they provide a service without prior authorization.
If you are seeking treatment from an out-of-network provider you are financially responsible for office visits and all other treatment if the provider does not receive prior authorization.
How does prior authorization work?
Expert reviewers will compare the request for medical treatment with the latest evidence-based guidelines. If the reviewer determines that the requested treatment is not medically necessary based on these guidelines the prior authorization request will be denied.
Most requests are processed within 2 — 3 business days.
If the request is denied you will receive a letter from us or one of our review partners outlining the reason for denial and explaining your rights as a member.
These include:
- Requesting a clinical consultation with your provider and expert reviewers
- Filing a formal appeal
Your denial letter will include instructions about these options.
Questions?
If you have questions, please contact our customer service team at 877-605-3229.
To learn more about prior authorization for injectable medications, please see our FAQ.
To learn more about prior authorization for advanced imaging and other services, please see this eviCore FAQ.
Questions?
If you can't find an answer, please feel free to contact our Customer Service Customer Service Customer Service
Questions?
If you can't find an answer, please feel free to contact our Customer Service
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