What to know about medical prior authorization
Why it’s needed, who’s responsible and how to get it.
Prior authorization, explained
You may have been told that a certain healthcare service or treatment requires prior authorization. That means that before you move forward and schedule your appointment, we'll need to review and confirm whether or not the service will be covered under your plan. It’s part of our job as your health plan to make sure that you receive the right care at the right time and at the most affordable price.
Without the protection of a prior authorization process, patients can be at risk for unnecessary treatments. In fact, doctors estimate that more than 20% of medical care is unnecessary and studies show that overuse of testing and treatment can lead to worse results for patients. This could include exposing patients to radiation from unnecessary CT scans and X-rays.
To see a list of services that require prior authorization, log in to your Member Dashboard and view your Member Handbook.
The prior authorization process
It is your provider’s responsibility to obtain authorization before they provide treatment. However, depending on whether or not your provider is in network, you may be financially responsible.
In-network providers are financially responsible if they provide a service without prior authorization.
You are financially responsible if you seek treatment from an out-of-network provider and they do not first receive prior authorization.
The prior authorization process
It is your provider’s responsibility to obtain authorization before they provide treatment. However, depending on whether or not your provider is in network, you may be financially responsible.
In-network providers are financially responsible if they provide a service without prior authorization.
You are financially responsible if you seek treatment from an out-of-network provider and they do not first receive prior authorization.
Prior authorization reviewers
Our expert reviewers will compare the request for medical treatment with the latest evidence-based guidelines. These guidelines are used in the healthcare field to identify scientifically supported, effective and safe treatments. Requests that meet evidence-based guidelines will be considered medically necessary and will receive prior authorization. Requests that don’t meet these guidelines will be denied. Most requests are processed within 2 to 3 business days.
Your options if your request is denied
You will receive a letter from Moda Health, Prime Therapeutics or EviCore explaining the reason for denial and providing instructions on how you can exercise your rights as a Moda Health member, including:
- Requesting a clinical consultation with your provider and expert reviewers
- Filing a formal appeal
Questions? We’re here to help.
Reach out to the Moda Health Customer Service team at 877-605-3229.
To learn more about prior authorization for injectable medications, please see our FAQ.
To learn more about prior authorization for advanced imaging and other services, please see this EviCore FAQ.