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Prior approval

When to seek prior approval

For all other Health Advantage health plans, some benefits provided by your Health Advantage health plan may require approval in advance of receiving medical services. Contact customer service if you have questions about prior authorization.

The following services always require prior authorization:

  • All out-of-network services
  • Breast reductions (not related to cancer)
  • Enteral formula
  • IDET (Intradiscal Electrothermal Annuloplasty)
  • Select injectable medications
  • Swing bed care (prior approval by case management)
  • Transplants (excluding kidney and cornea)

Prior approval information for high-tech scanning procedures

High-tech imaging (scanning) procedures are one of the most rapidly rising medical expenses. The following high-tech scans are not only causing premiums to increase; most are exposing patients to higher doses of radiation. Health Advantage requires physicians to obtain a prior approval when ordering the following outpatient high-tech imaging procedures for their patients:

  • PET scans
  • CT scans
  • MRI/MRA
  • Nuclear cardiology

Note: Physicians are not required to obtain an authorization when these services are performed in an emergency room, observation bed stay or for patients who are hospitalized.

What is Health Advantage doing to help?

Health Advantage has implemented a program that requires physicians to obtain an authorization when ordering outpatient high-tech imaging procedures for their patients. Physicians are not required to obtain an authorization when these services are performed in an emergency room, observation bed stay or for patients who are hospitalized.

Simplifying the process

The approval process generally is fast and efficient but, as with any new program, there have been minor glitches. Health Advantage is working to simplify the process for physicians.

What you need to know

  • If your physician fails to get an authorization, you will not be held financially responsible if the service is provided by an in network facility.
  • The imaging facility may not perform the scan until an authorization has been received.
  • Prior approval is not a guarantee of payment. Your benefit plan may have exclusions or limitations that may apply.

For more information

Contact the office location in your area.