Getting Approval for Care
Some services, medications, and long-term care supports require approval before your plan covers them. The type of approval you need depends on the service you are requesting.
Understanding which approval process applies to your situation is the first step.
Some services, medications, and long-term care supports require approval before your plan covers them. The type of approval you need depends on the service you are requesting.
Understanding which approval process applies to your situation is the first step.
Types of Approval
Prior Authorization
Prior authorization is the process used for certain Medicare-covered medical services. Before some services are provided, your plan reviews the request to confirm the service is medically necessary and covered under your plan.
Examples may include:
- Certain outpatient procedures
- Advanced imaging services
- Durable medical equipment
- Medicare Part B drugs
Service Authorization
Service authorization is the process used for certain Medicaid-covered long-term services and supports. Before some services begin, change, or continue, your plan reviews the request to determine whether the service is medically necessary and appropriate based on your needs.
Examples may include:
- Personal Care Services
- Consumer Directed Personal Assistance Services (CDPAS)
- Adult Day Health Care
- Home-Delivered Meals
- Private Duty Nursing
Prescription Drug Coverage Determinations
Some prescription drugs may require prior authorization, step therapy, quantity limits, or other coverage rules. These requests are reviewed through your prescription drug benefit.
Not Sure Which Approval Process Applies?
If you are unsure whether a service requires prior authorization, service authorization, or a medication coverage determination, Member Services can help.