How we handle preauthorizations so you can best treat your patients Preauthorization is the procedure for confirming, prior to the rendering of care, the medical necessity and appropriateness of the proposed treatment, and whether (and if so, to what extent) such treatment is a covered benefit for the covered person. Whether preauthorization is required, and if so, how and when it must be obtained, depends on the kind of treatment and whether the provider is a participating provider or a non-participating provider.
If you use a participating provider for any of the above treatments or procedures, the provider is responsible for preauthorization. You are advised to verify with the physician that preauthorization procedures have been followed. If you use a non-participating provider for any of the above treatments or procedures, you are responsible for obtaining preauthorization, and benefits may be denied or reduced if you fail to timely obtain preauthorization, as follows:
If you are responsible for obtaining preauthorization (i.e., you are using a non-participating provider), and you fail to do so in the required time, EMI Health will review the treatment and apply the following penalties:
To initiate a preauthorization for a prescription, the prescriber must request the preauthorization using one of the following methods:
Preauthorization is not a guarantee of payment. Payment for preauthorized services and/or prescriptions is contingent upon eligibility and benefits at the time of service. All terms and provisions of the plan will apply, and any services and/or prescriptions in connection with a preauthorization approval that are exclusions or limited benefits will be reimbursed accordingly. Services and/or prescriptions that are exclusions of the policy will be denied; services that have plan limitations will be paid according to those limitations. For more information, or if you have questions, contact our provider assistance team at 801-262-7975 or toll free at 800-644-5411. |