Prior Authorization is a process in place to review requests by providers for the provision of health care services to members. This includes the use of criteria or guidelines to determine whether to approve, modify or deny, based on medical necessity and benefit coverage.
Prior Authorization is required for all but not limited to the following:
- A. All off-island services:
- Referrals, evaluations, hospitalizations, surgeries, procedures, services, and/or treatments.
B. Inpatient and related services:- All scheduled surgical inpatient admissions, excluding cesarean sections.
C. Outpatient, in-office and related services:- Outpatient surgical procedures, excluding maternity care.
- Outpatient services/treatment:
- Cancer care (consultation, chemotherapy/radiation therapy)
- Self-injectibles
- Sleep studies
- Neuropsych testing
- Radiological/nuclear/magnetic resonance scans:
- MRI/MRA
- CT scan
- Spiral CT scan
- Bone density studies
- Appliance/prosthetics/DME*:
- Corrective appliances, orthotics, prosthetics, custom braces
Your Primary Care Physician will refer you to a specialist for needed care. Certain specialty services will require Prior Authorization. Your Primary Care Physician will normally submit a request to the Medical Management Department and obtain approval before those services can be rendered. The Medical Management Department communicates with your Primary Care Physician once an approval is given.
Your Primary Care Physician must complete a Prior Authorization request form to be forwarded to the Medical Management Department. To expedite the review process, all pertinent records and documents must be submitted to support the request. Medical Management uses strict guidelines and criteria in its review process determine whether to approve, modify or deny, based on medical necessity and benefit coverage.
You must obtain a referral from your Primary Care Physician if you need off-island care. Medical Management must coordinate and prior authorize your care to specific qualified facilities to limit your out of pocket costs as well as to provide coverage under your participating network benefits. If you require additional visits, tests or services, you will need to work with the physician and/or facility together with the Medical Management Department in advance for coordination and authorization for additional services.
If you are in an emergency situation, you do not need prior authorization to access emergency care services. However, if you were admitted in a hospital as a result of an emergency, you still need to notify Medical Management within 48 hours unless it was not reasonably possible to do so, otherwise your care may not be covered.