Physicians, health care professionals and ancillary care providers are responsible for:
- Providing advance notification or requesting prior authorization for services on the Advance Notification/Prior Authorization List.
- Directing members to use care providers within their network. Members may be required to obtain prior authorization for out-of-network services.
Facilities are responsible for:
- Confirming coverage approval is on file prior to the date of service.
- Providing admission notification for inpatient services even if coverage approval is on file.
If you perform multiple procedures for a member in one day, and at least one service requires prior authorization, you must obtain prior authorization for any of the services to be paid.
If you do not follow these requirements, we may deny claims. In that case, you cannot bill the member. Advance notification or prior authorization is valid only for the date of service or date range listed on it. If that specified date of service or date range has passed, you must submit a new request.
- Giving us advance notification, or receiving prior authorization from us, is not a guarantee of payment, unless required by law or Medicare guidelines. This includes regulations about care providers on either a sanctions and excluded list, and/or care providers not included in the Medicare Provider Enrollment Chain and Ownership System (PECOS)* list. Payment of covered services is based on:
- The member’s benefit plan,
- If you are eligible for payment,
- Claim processing requirements, and
- Your participation agreement with us.
See Coverage Determinations and Utilization Management Decisions section for additional details.
Information Required for Advance Notification/Prior Authorization Requests
Your request must have the following information:
- Member name and member health care ID number
- Ordering care provider name and TIN or National Provider Identification (NPI)
- Rendering care provider name and TIN or NPI
- ICD-10-CM diagnosis code
- All applicable procedure codes
- Anticipated date(s) of service
- Type of service (primary and secondary) procedure code(s) and, if relevant, the volume of service
- Place of service
- Facility name and TIN or NPI where service will be performed (when applicable)
- Original start date of dialysis (End Stage Renal Disease (ESRD) only)
If the member’s benefit plan requires a clinical coverage review, we may request additional information, as described in more detail in the Clinical Coverage Review.