Prior authorization

As you navigate your health care, it’s important for you to know that there are certain medical services or provider visits that require prior authorization by Prevea360 Health Plan.

These authorizations are required so our Utilization Management team can review the medical necessity of the recommended service or visit and make sure you are getting the appropriate care. Services provided in the emergency room do not require a prior authorization.

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.

When we receive a request from your provider, if it is prior to the service being provided (prior authorization) the determination is made within 72 hours of receiving an urgent request or within 15 calendar days of receiving a non-urgent request. If the request is received while you are receiving a service, such as an inpatient admission (urgent concurrent request), the determination is made within 24 hours or as soon as the necessary medical information is received but will not exceed 72 hours. If the request is received after the service has been completed (post-service) the determination is made within 30 calendar days.

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. Be aware that you will be financially responsible for the full cost of any service or drugs if the authorization your provider has submitted is denied.

What type of insurance plan do you have?

Confirm your plan by referring to your Prevea360 ID card.

I have a network (HMO) plan

Did your primary care physician (or other in-network provider) refer you to an in-network or out-of-network provider/specialist for the recommended service?

In-network

A prior authorization is not required for you to see an in-network provider. However, some services that the in-network provider might recommend may require a prior authorization. If the in-network provider recommends a service that requires prior authorization, it is up to your in-network provider to obtain the prior authorization for you. If you don't obtain a prior authorization for a service or drug when required—or if it is denied—you may be financially responsible for the full cost of that service or drug.

Out-of-network

If your Prevea360 Health Plan provider is recommending you see a physician or specialist outside of the Prevea360 Health Plan network, you are required to have an approved authorization before your visit. Your Prevea360 Health Plan provider 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.

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 or drugs with an out-of-network provider if the authorization your provider has submitted is denied or if you don't obtain prior authorization.

I have a PPO or POS plan

Because each POS and PPO plan is different, we recommend you check to see if a prior authorization is required for any services outside a normal office visit.

You'll receive our determination by mail or you can call our Customer Care Center to check on the status of the prior authorization.

Remember, if a service requires prior authorization and one is not obtained—or if prior authorization is denied—you could be subject to a penalty in addition to your other out-of-pocket expenses.

For a plan-specific list of these services, refer to the prior authorization section of your Member Certificate, or contact Customer Care.

Out-of-area care

Urgent and Emergency Care

You do not need a referral or authorization for urgent and emergency care. Prevea360 Health Plan covers urgent and emergency services while you are outside of our service area (subject to member policy copays, coinsurance and deductibles).

If you need urgent or emergency care please go to the nearest medical facility or call 911.

For more information on emergency services, see our no surprises Q&A.

Follow-up care

Follow-up appointments to an out-of-area urgent or emergency visit should be made with a Prevea360 Health Plan provider. If this is not possible, please contact your home primary care physician for a prior authorization to an out-of-network provider.

Calling the Customer Care Center can also help you verify a provider in that area who is covered under our nationwide network. You can also see the Customer Care number on your Member ID.