The list of services that require advance notification and prior authorization is the same. The process for providing notification and submitting a prior authorization request is the same. Services that require prior authorization require a clinical coverage review based on medical necessity.
Advance Notification/Prior Authorization Lists are available online. They are subject to change. We notify you of changes through the Network Bulletin.
If you need a paper copy of the requirements, please contact your Network Management representative or Physician Advocate.
View the most current and complete Advance Notification Requirements, including procedure codes and associated services, go to: Advance Notification and Plan Requirement Resources.
When to Submit Advance Notification or Prior Authorization Requests
After submitting your request, you get a service reference number. This is not an authorization. When we make a coverage determination, we issue it under this reference number.
We recommend that you submit advance notification with supporting documentation as soon as possible, but at least two weeks before the planned service (unless the Advance Notification Requirements states otherwise). Following a facility discharge, advance notification for home health services and durable medical equipment is required within 48 hours after the start of service.
It may take up to 15 calendar days (14 calendar days for MA) for us to make a decision. We may extend this time if we need additional information.
We prioritize case reviews based on:
- Case specifics
- Completeness of the information received
- CMS requirements
- State or federal requirements
If you require an expedited review, please call the number listed on the back of the member’s health care ID card. You must explain the clinical urgency. You will need to provide required clinical information the same day as your request.
We expedite reviews upon request when the member’s condition:
- Could, in a short period of time, put their life or health at risk
- Could impact their ability to regain maximum function
- Causes severe, disabling pain (as confirmed by a physician)