Prior authorizations: What they are and when you need them
September 25, 2020
There are lots of great ways you can take advantage of your healthcare benefits through SmartHealth. One of these is prior authorizations. What are prior authorizations? It is the process used by providers to obtain advance approval from SmartHealth before certain services can be performed. Nationally recognized guidelines are utilized to determine the medical necessity of service. Your provider must complete a prior authorization form and submit clinical information for review.
How do you obtain prior authorization?
The first step in obtaining prior authorization is checking to see if a procedure or service needs it. You can review a complete list of services that require prior authorization at www.mysmarthealth.org. Just go to the Information Center and click on a section labeled “Prior Authorization.”
The next step is completing the prior authorization form. Your provider must complete the form. They must submit the completed form along with supporting clinical information for review. Only providers can submit the form for prior authorization. The timeline to review requests for prior authorization varies depending on what service is being requested. For example, elective non-urgent procedures should be requested at least 14 days in advance.
Why is prior authorization important?
This process is important because it helps determine if a service or recommended treatment is medically necessary and appropriate. In this case, it is helpful for both you and your doctor.
Important things to note:
- While your provider initiates the prior authorization request for you, it is your responsibility to make sure that you obtain prior authorization before receiving certain health care procedures and services. If prior authorization is not obtained, the member may be responsible for the resulting medical costs.
- Prior authorization must be obtained before the healthcare services are performed or the resulting medical costs may become the responsibility of the member.
- If the prior authorization request is approved, your provider will be notified.
- If your prior authorization request was not approved, both you and your provider will receive a letter in the mail explaining the reasons why the service could not be approved and your appeal options.