Disclaimer Pre-certification / Pre-authorization Information

Pre-certification / Pre-notification

Preadmission certification or pre-certification is a process where a member must call and receive prior approval for an admission into any hospital. Failure to receive preadmission certification usually involves a penalty payment by the member of a specified dollar amount – varies by plan design. Health Advantage no longer requires preadmission certification.

Pre-notification is a process where a member should call in prior to admission to an out-of-network hospital facility or a hospital outside the state of Arkansas to alert us of the admission. Pre-notification provides information helping to determine if case management would be an appropriate option for the member. Pre-notification is not required for outpatient treatment or any in-state, in-network inpatient admissions.

Pre-authorization / Prior authorization:
Prior authorization or pre-authorization is a review prior to the time a specified procedure is scheduled. This review consists of checking clinical documentation to verify the medical necessity for the procedure. The review is done by Health Advantage, National Imaging Associates (NIA), and New Directions based on medical guidelines from Health Advantage. A prior authorization is required for each different procedure, even if those procedures are performed on the same day. Failure to obtain prior authorization will result in denial of the claim.

Procedures requiring prior authorization:

Some benefits provided by your Health Advantage health plan may require approval in advance of receiving medical services. Contact Customer Service if you have questions about prior authorization by calling 501-378-2363 or 1-800-843-1329.

The following services always require prior authorization:
  • All out-of-network services
  • Breast reductions (not related to cancer)
  • Enteral formula
  • Select injectable medications
  • Swing bed care (prior approval by case management)
  • Transplants (excluding kidney and cornea)
  • Out Patient Hospitalization for anesthesia for dental services
NIA — Specified high tech radiology procedures, MRI's, CT's, PET scans, and nuclear cardiology, must have prior authorization. Inpatient services, emergency room services and observation room services are not subject to this review. For prior authorization, call NIA at 1-877-642-0722. Radiology Management Reference Guide (PDF): Detailed information regarding the new prior authorization program for outpatient diagnostic imaging services.

New Directions — (Still applies if insurance is secondary payor.) For authorization, call New Directions at 1-877-801-1159.
  • Inpatient stays
  • Emergency admission (next business day)
  • Partial hospitalization program
  • Intensive outpatient program
  • Prior to 9th outpatient visit
    • HMO and POS plans always require a referral; Open Access POS plan will require a referral after the first 8 visits for non-MD’s.
Pharmacy prior authorization:

Please contact CVS Caremark at 1-877-433-2973 (Monday — Friday from 8 a.m. — 6 p.m. CST) to request approval for a prescription drug that requires a prior authorization. Exceptions for 1) prescription drug fertility treatments, 2) dosages in excess of the plan’s quantity limits, 3) step therapy, and 4) drugs not covered by the plan are handled by the plan and can be requested by calling 501-378-3392 (Monday — Friday from 8 am — 4:30 pm CST).





Health Advantage is an Independent Licensee of the Blue Cross and Blue
Shield Association and is licensed to offer health plans in all 75 counties of Arkansas.
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