Understanding Medical Prior Authorization
What Is Prior Authorization?
A prior authorization is sometimes referred to as a pre-certification, pre-authorization, or pre-service approval. Each term refers to the same process. It is the process where doctors and providers ask HealthSpring to approve certain medical services to be covered by your insurance plan.
When you go through the prior authorization process, HealthSpring reviews the service you’ve asked for to find out if it’s a medical necessity and appropriate for your needs. This review doesn’t replace the advice of your provider.
Some examples of services that may need medical prior authorization are:
Home health care
Specialist or specialty care visits (other than your primary care provider)
Infusions
Injections
Outpatient surgical procedures
Durable medical equipment
Non-emergent ambulance transport
Outpatient diagnostic testing
Outpatient therapy
Why Are Prior Authorizations Important?
A medical prior authorization allows HealthSpring to:
Check that the service or medicine requested is covered by your plan for your health condition
Make sure the care is appropriate and medically necessary based on trusted clinical guidelines
Protect our members’ health and finances by reviewing certain high-cost or higher-risk services before care is provided
Review services to make sure they are given by the appropriate provider in an appropriate setting
How Prior Authorization Decisions Are Made
HealthSpring uses Medicare guidelines and internal medical policies to help you get health care you need.
HealthSpring or one of our delegated vendors will administer utilization management review and care management services. Except in the case of an emergency medical condition, we’ll provide prior authorization for those services if required by the member’s benefit plan, including services received while you are staying in a hospital.
We base utilization-related decisions on your specific clinical and health care needs, benefit plans and the appropriateness of care employing well-established clinical decision-making tools. We also consider current evidence in widely used treatment guidelines and clinical literature, taking into account information provided by the provider or member. Criteria we may consider during the clinical review process include:
Centers for Medicare & Medicaid Services’ National Coverage Determinations
American Society of Addiction Medicine Clinical Guidelines
HealthSpring Medical Policies
EviCore Clinical Guidelines
American Specialty Health Medical Coverage Policies
WellMed® Medical Coverage Policies
Member Evidence of Coverage
You should always talk to your provider about any specific health questions or concerns. You can also check with them if you have questions about prior authorizations or medical policies.
How Can I Find Out if My Treatment or Service Requires a Prior Authorization?
Certain services like surgeries, advanced imaging, specialty medications and some behavioral health treatments need prior authorization.
Here’s how to find out:
Ask your doctor or provider: In most cases, your doctor or provider will know if prior authorization is needed and will submit the request for you.
Review your Evidence of Coverage (EOC): You can review services that need Medical Prior Authorization within your EOC.
Call HealthSpring customer service: If you’re unsure, call the number on your HealthSpring member ID card for help.
Emergency services are excluded from prior authorization requirements. An emergency is a medical condition that may cause immediate harm to your health.
How Do I Request Prior Authorization?
Most of the time, your doctor will take care of prior authorization for you. Providers submit a request and get approval before they offer your care. But it’s always a good idea to check, especially if your doctor's not in your plan network. If you use an out-of-network doctor, you may need to handle prior authorization for yourself.
To make a prior authorization request directly, call the number on your HealthSpring member ID card.
When you call, you will be asked for the following information:
Your name, member ID number and date of birth
Your provider’s name, address and National Provider Identifier (NPI)
Information about your medical or behavioral health condition
Your provider's proposed treatment plan, including any diagnostic or procedure codes
When you'll get care and, if you're being admitted, an estimated length of stay
Where you’re being treated
Prior Authorization Statistical Data
To follow the CMS Interoperability and Prior Authorization rule, HealthSpring provides yearly information about our prior authorization requests. This includes a list of medical items and health care services that need prior authorization and data about last year’s requests.
This information does not include data from drug authorizations, and you can view the report here:
This report includes:
The percentage of standard and urgent prior authorization requests that were approved or denied.
Average and middle wait (median) review turnaround times for standard and urgent requests.
The percentage of requests that were approved after appeal.
Frequently Asked Questions
Does Original Medicare have prior authorization requirements?
For some services, medicine, or medical equipment, yes. Original Medicare may require prior authorization for certain types of care that are more complex or costly.
Until 2020, Original Medicare didn’t require any approval before receiving services. Since then, the Centers for Medicare and Medicaid Services (CMS) has added prior authorization requirements for some services. Original Medicare still has fewer requirements than some other Medicare options, like Medicare Advantage.
Why was my prior authorization denied? Can I request an appeal?
If your prior authorization request is denied, you and your doctor have a few options:
You can request an appeal. Your prior authorization request will go through another review with the extra details shared by your provider.
Your doctor can change their approach to care.
Once a decision for your request is made, you’ll get a letter from us. If your request was denied, the letter will include information about the appeal process. To find more information about your right to appeal, visit our Medicare Appeals Process page.
If you still choose to get the service or drug after your prior authorization request was denied, you’ll have to pay the costs out of your own pocket.
Why does prior authorization exist and how does it help me?
Some health care services can be expensive or have high risks. Prior authorization helps make sure you get the right care for you, especially when your provider recommends a more costly or complex approach to care.
Prior authorization helps protect everyone involved; you, your doctor and your health plan. During the prior authorization process, HealthSpring or a company on behalf of HealthSpring will review the requested service or medication to see if the service or medication is medically necessary.
How often are prior authorization requirements updated?
Prior authorization requirements are updated regularly to align with program or code changes.
Where can my doctor or treating provider find more information on prior authorization requirements or how to submit a request?
Providers may access information on prior authorization requirements, how to request an authorization, and more on our provider website.