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Medical necessity and prior authorization timeframes and member responsibilities

Services requiring prior authorization

Prior authorizations are submitted by the provider and serve as a process through which Health Advantage determines the medical necessity of a covered healthcare service before the member receives the service. Most policies no longer require prior authorization for medical services but will require prior authorization for certain prescription drugs. However, group plans offered by your employer that are administered by Health Advantage may still require prior authorization for both medical services and certain prescription drugs. When prior authorization is required, prior authorization must be requested and approved before the member receives services. If not requested, the claim will be denied. Please note that if a request for prior authorization is approved for medical necessity, the service still must meet all other coverage terms, conditions, and limitations of the member's policy (See section below for the Denial of Services with Prior Authorization).

Group plans administered by Health Advantage 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 approve a prior authorization request for coverage if medical necessity is supported. However, a request for prior authorization, if approved for medical necessity, does not guarantee payment. A claim receiving prior authorization approval still must meet all other coverage terms, conditions, and limitations of the policy covering the member's benefits. Coverage for any such claim receiving prior authorization may 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 (2) business days from the date the service claim was received. Additional information regarding medical necessity and prior authorization can be found in the member's benefit certificate.

If you have need to verify whether your plan requires prior authorization, you may contact Customer Service at 800-843-1329 for more information.