Prior Authorization
Prior Authorization (Pre‑Authorization) is an often times required review process used to determine whether certain medical services are medically necessary before they are received.
What services may require Prior Authorization?
All inpatient hospitalizations and procedures performed at an outpatient surgical facility must be pre‑authorized. Your health plan documents describe which services may require Prior Authorization. When in doubt, members are encouraged to confirm requirements in advance.
Who Manages the Prior Authorization Review?
Prior Authorizations are coordinated through a Professional Review Organization 1-800-275-7916
Who Manages the Prior Authorization Review?
Prior Authorizations are coordinated through a Professional Review Organization 1-800-275-7916
What Steps Must I Take to Comply with Prior Authorzation Requirement?
To meet Prior Authorization requirements, the covered person must:
- Contact the Professional Review Organization
Provide required information
- Follow all instructions from the Professional Review Organization
- Submit any medical records, forms, or documentation they request
Notify your healthcare providers
- Inform all providers that your coverage includes Prior Authorization requirements
- Ask providers to fully cooperate with the Professional Review Organization during the review process
What happens if Prior Authorization is Approved?
If the covered person complies with the Prior Authorization requirements and the services are pre‑authorized, eligible expenses will be considered for coverage subject to all plan terms, conditions, limitations, and exclusions.
What happens if Prior Authorization is Completed?
If Prior Authorization is required but not obtained, or if the expenses are not pre‑authorized, covered expenses may be reduced by 50%, depending on the plan. This primarily applies to plans where Prior Authorization is a condition of payment (such as certain Short‑Term Medical plans).
Does Prior Authorization Apply Differently by Plan Type?
Short-term Medical (STM) Plans
- Certain services require Prior Authorization
- Failure to obtain required Prior Authorization may result in denied or reduced benefits
- Members should confirm requirements before receiving services
Fixed Indemnity (FI) Plans Benefits are not denied or reduced for failing to obtain Prior Authorization, however, Prior Authorization is still encouraged because it:
- Helps confirm medical necessity
- Supports appropriate use of benefits
- Helps manage overall healthcare costs
What if There is a Medical Emergency?
In the event of an Emergency Medical Condition, Prior Authorization must be completed after the patient has been stabilized. Emergency care should never be delayed to obtain Prior Authorization.
Does Prior Authorization Guarantee Benefits Will be Paid?
No. All claims remain subject to:
- Plan terms and conditions
- Coverage limitations
- Exclusions
- Final claims review
Who Should I Contact If I Have Questions?
Call the Professional Review Organization at 1‑888‑275‑7916
Contact Member Services or Refer to your plan documents
*Pre-auth not required for AZ residents with Fixed Indemnity plans.
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