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Medical necessity and prior authorization timeframes and member responsibilities

Services requiring prior authorization

Prior authorization is a process though which Health Advantage approves a request for a covered healthcare service before the member receives the service from a provider. Prior authorization must be requested and approved before the member to receives services. If not, the claim will be denied. Health Advantage member contracts require prior authorization for the following:

  • hospital services with anesthesia for complex dental conditions
  • advanced diagnostic imaging
  • in vitro fertilization and infertility
  • applied 54 behavioral analysis
  • durable medical equipment for which costs exceed $5000
  • surgically implantable osseointegrated hearing aids
  • prosthetic devices for which costs exceed $20,000
  • corrective surgery for craniofacial anomalies
  • reduction mammoplasty
  • certain prescription medications
  • most organ transplants
  • admission to neurologic rehabilitation facilities
  • some pediatric vision services
  • enteral feedings
  • gastric pacemakers
  • gender reassignment
  • bariatric surgery
  • hospice
  • home health

This list is not exhaustive.

Denial of services with prior authorization

Health Advantage will authorize coverage if medical necessity is supported. However, a request for prior authorization, if approved, does not guarantee payment. A claim receiving prior authorization as a pre-service claim must still meet all other coverage terms, conditions and limitations. Coverage for any such pre-service claim receiving prior authorization may still be limited or denied if investigation shows that:

  • a benefit exclusion or limitation applies
  • the covered person ceased to be eligible for benefits on or before the date services were provided
  • coverage lapsed for non-payment of premium
  • out-of-network limitations apply
  • any other basis specified in the policy applies to limit or exclude the claim.

If no additional information is requested, you will be notified of the determination in no later than two business days from the date the pre-service claim was received. Additional information regarding medical necessity and prior authorization can be found in the member contract.