Understanding Prior Authorization
What is prior authorization?
Prior authorization is the process where doctors and providers ask HealthSpring to approve certain health care services or prescription drugs to be covered by your insurance plan. This is also known as preauthorization, pre-certification or prior approval.
When you go through the prior authorization process, HealthSpring reviews the service or drug you’ve asked for to find out if it’s a medical necessity and appropriate for your needs. This is part of a larger process called utilization management. Review does not replace the advice of your provider.
How do you 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, start by calling 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 are being treated
Search In-Network Care
Check If Your Doctor is In-Network
Log in to your myHealthSpring member account to search for in-network doctors, hospitals and providers.
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:
Separate data for standard and expedited (fast/urgent) requests
How many requests we approve and deny
How many are approved after an appeal or extension
How long it most often takes to make a decision