Prior authorization reviews

When you submit a prior authorization request, Review Services reviews your coverage request and then will either approve or deny it — this is an initial review. If Review Services denies your coverage request, you may request an appeal on your patient's behalf.

Note: The second level review described on this page is part of the prior authorization process and is not an appeal.

First-level reviews

When you submit a coverage request that requires a medical necessity review, clinical specialists perform the review. They base coverage decisions on clinical criteria, the member's medical records, and any other relevant information.

For requests that require medical necessity review, it is required that supporting documentation related to the services being requested be submitted at the time of your request, in order for a thorough review to be completed. Lack of supporting documentation may result in the request being denied.

If the initial reviewer cannot approve the coverage request, they forward the coverage request to a physician, pharmacist, or licensed psychiatrist.

To expedite patient care, please check the CPT code in the Pre-Auth Code Check Tool. The tool will inform you if an authorization is needed. If it is needed and there is documentation indicated for the review, please attach those records to your referral request in Affiliate Link.

Second-level reviews

If the first-level review resulted in a denial recommendation, a physician, pharmacist, or licensed psychiatrist will consult with the referring practitioner or specialists as appropriate. If the second-level reviewer denies the coverage request, the reviewing unit will issue a written notice of noncoverage.

Notice of noncoverage

A written notice of noncoverage will be mailed to the member and to the provider.

The notice of noncoverage includes:

  • Rationale for the denial.
  • Detailed review criteria or benefit provisions used in the determination, and instructions for how to obtain a copy of the review criteria.
  • Details about how to initiate a member appeal, either expedited or standard.
  • Information about how a practitioner can contact the reviewer regarding how the reviewer made their decision.

Content on this page is from the provider manual | Disclaimer