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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:
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:
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.