Prior authorization

Understanding prior authorization

Medical necessity and enrollee responsibilities

As you navigate your health care, it’s important to note there are certain medical services or provider visits that will require prior authorization by WellFirst Health. The process below will help walk you through whether you need a prior authorization. Services provided in an emergency room do not require a prior authorization. If you receive services without an approved prior authorization request, the claim may be denied if it is not found eligible for coverage. You may be financially responsible for the full cost of any service or drug for which prior authorization was not requested when required.

Why?

WellFirst Health requires these authorizations so our Utilization Management team can review the medical necessity of the recommended service or visit and make sure you are getting appropriate care.

Is it covered?

Keep in mind, a prior authorization will not change the benefits under your plan. If a service is an exclusion of your plan, a prior authorization will not change the fact that the service is not a covered benefit.

If the services are covered under your plan, and you have an approved prior authorization, the services are subject to any applicable cost sharing (i.e. copays, co-insurance or deductibles).

To find out if a service is a covered benefit under your plan:


Getting prior authorization

Some medical services require approval by WellFirst Health before you receive them. Our prior authorization process helps ensure you receive medically necessary care at the right time with the right provider. Your plan provider should submit prior authorization requests as soon as possible and prior to your scheduled services to ensure a determination can be made prior to their receipt. Standard requests have a turnaround time of 36 hours, including one business day.

Medical necessity means that the treatment, services or supplies from your provider or hospital are required to identify or treat your illness or injury. We will determine if they are:

  • Consistent with your illness or injury
  • Generally accepted standards of medical practice
  • Not solely for the convenience of a member, hospital, or other provider
  • The most appropriate supply or level of service that can be safely provided to the Member in the most cost effective manner.


Just because a doctor has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for an injury or illness doesn't mean that it is medically necessary. 

Out-of-network physician or specialist

If your WellFirst Health provider is recommending you see a physician or specialist outside of the our network, they must submit the prior authorization request for review. You’ll receive our determination by mail or you can call our Customer Care Center to check on the status of the prior authorization.  

We recommend that you wait for a determination regarding your request before receiving services with an out-of-network provider. Be aware that you will be financially responsible for the full cost of any service with an out-of-network provider if the authorization your provider has submitted is denied.

Medical procedure or service

If your provider recommends you receive a procedure or medical service, a prior authorization may be required. If it is required, your WellFirst Health provider is responsible for obtaining the approval before providing the procedure or service.

Steps to take

Your provider will help you coordinate the care you need. All plan providers have someone who works on acquiring authorizations for their patients.

To find out if a service or procedure requires a prior authorization:


When we receive a prior authorization request from your plan provider, we typically decide on requests for prior authorization for medical services within 36 hours including one business day. Remember, even with a prior authorization, not all services are covered at 100%. You will be responsible for the co-pays and deductibles outlined in your Member Certificate.