These prior authorization submission requirements apply to participating healthcare professionals for Exchange Plans members in Arizona, Maryland, North Carolina, Oklahoma, Tennessee, Virginia, and Washington. You can find the procedure and service codes that will require prior authorization for these members at Plan Requirements for Advance Notification/Prior Authorization > Exchange Plans Advanced Notification / Prior Authorization Requirements.
Submitting Prior Authorizations:
Participating providers must submit prior authorization requests for Exchange Plan members electronically (online through the Prior Authorization and Notification tool on Link or via EDI 278N). If you do not submit prior authorization requests electronically we will not process your request.
Starting Oct 15, 2020, additional information will be available by state at the following:
New to the Prior Authorization and Notification Tool?
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Need technical help?
Please email or call our Help Desk at 866-842-3278, option 1. Representatives are available Monday - Friday 7 a.m. - 9 p.m. Central Time.
Required Referrals: Some Exchange Plans services will require referrals. We will send participating providers more information on referral requirements later this month. General referral requirements will include the following:
Specialist Referral Requirements: Any eligible service provided by the specialist in any setting requires a referral. The member’s assigned Primary Care Provider (PCP), or a primary care provider within the same TIN must submit electronic referrals through referralLink to be Referrals on Link when care is needed by a network specialist. Once the referral end date has passed or the number of visits is exhausted, the member must contact their PCP to request a new referral before receiving additional care. Specialists should confirm a valid referral is on file before each office visit, as members seen without a valid referral on file may have no coverage.
When determining coverage, the member specific benefit plan must be referenced as Exchange Plans vary by state.
Prior authorization is not required for emergency or urgent care.
Out of Network Coverage: For these Exchange Plans, members have no non-emergent out-of-network coverage and no coverage outside of the service area.
Check back regularly for more information on this and Exchange Plans topic that will be posted monthly on UHCprovider.com/networknews.