As you navigate your health care, it’s important for you to know that there are certain medical services or provider visits that require prior authorization by Prevea360 Health Plan.
These authorizations are required so our Utilization Management team can review the medical necessity of the recommended service or visit and make sure you are getting the appropriate care. Services provided in the emergency room do not require a prior authorization.
Medical necessity means that the treatment, services or supplies from your provider or hospital are required to identify or treat your illness or injury. We will determine if they are:
Just because a doctor has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for an injury or illness doesn't mean that it is medically necessary.
When we receive a prior authorization request from your provider, we typically decide on requests for prior authorization for medical services within 72 hours of receiving an urgent request or within 15 calendar days for non-urgent requests.
Remember, even with a prior authorization, not all services are covered at 100%. You will be responsible for the co-pays and deductibles outlined in your Member Certificate. Be aware that you will be financially responsible for the full cost of any service or drugs if the authorization your provider has submitted is denied.
Confirm your plan by referring to your Prevea360 ID card.
Did your primary care physician (or other in-network provider) refer you to an in-network or out-of-network provider/specialist for the recommended service?
A prior authorization is not required for you to see an in-network provider. However, some services that the in-network provider might recommend may require a prior authorization. If the in-network provider recommends a service that requires prior authorization, it is up to your in-network provider to obtain the prior authorization for you. If you don't obtain a prior authorization for a service or drug when required—or if it is denied—you may be financially responsible for the full cost of that service or drug.
If your Prevea360 Health Plan provider is recommending you see a physician or specialist outside of the Prevea360 Health Plan network, you are required to have an approved authorization before your visit. Your Prevea360 Health Plan provider must submit the prior authorization request for review. You'll receive our determination by mail or you can call our Customer Care Center to check on the status.
We recommend that you wait for a determination regarding your request before receiving services with an out of network provider. Be aware that you will be financially responsible for the full cost of any service or drugs with an out-of-network provider if the authorization your provider has submitted is denied or if you don't obtain prior authorization.
Because each POS and PPO plan is different, we recommend you check to see if a prior authorization is required for any services outside a normal office visit.
You'll receive our determination by mail or you can call our Customer Care Center to check on the status of the prior authorization.
Remember, if a service requires prior authorization and one is not obtained—or if prior authorization is denied—you could be subject to a penalty in addition to your other out-of-pocket expenses.
You do not need an authorization for urgent and emergency care if you are not able to return to the Prevea360 Health Plan service area for immediate treatment—and if the medical need is determined as such upon review.
Be sure you understand the types of care available to you and the Out-of-Area Coverage policy here at Prevea360 Health Plan before you leave town.
Urgent care should be received at the nearest appropriate medical facility unless you can safely return to the service area. Contact Prevea360 Health Plan by the next business day after seeing an out-of-network provider.
When we receive a claim for the services, it will be reviewed to determine if the diagnosis or symptoms were urgent. If so, payment will be based on our maximum allowable fee. You will be responsible for any fees that exceed this amount.
If you are outside of the service area and require emergency care, call 911 or go to the nearest medical facility. Contact Prevea360 Health Plan as soon as possible after receiving any emergency treatment or an emergency admission to a non-contracted facility.
If you are admitted to a non-contracted facility for inpatient behavioral health services, we request notification as soon as possible after being admitted. A non-contracted provider is a provider who does not have an agreement with the health plan and are considered non-plan.
For more information on emergency services, see our no surprises Q&A.
Follow-up appointments to an out-of-area urgent or emergency visit should be made with a Prevea360 Health Plan provider. If this is not possible, please contact your home primary care physician for a prior authorization to an out-of-network provider.
Calling the Customer Care Center can also help you verify a provider in that area who is covered under our nationwide network. You can also see the Customer Care number on your Member ID.