Some prior authorization requests require documentation in addition to the prior authorization form to support a determination of medical necessity. To see which documentation is necessary for a prior authorization request, go to:
If a prior authorization request lacks the necessary information to determine medical necessity, we will return the request to the requesting provider with a letter describing the documentation that needs to be submitted.
When possible, we will contact the requesting provider by telephone and obtain the information necessary to complete the prior authorization process. Otherwise, we will return the request to the requesting provider with a letter describing the documentation that needs to be submitted.
If the information is not provided within 16 business hours of our request for additional information, we will send a letter to the member explaining that the request cannot be acted upon until the information is provided. We’ll also send a copy of the letter that was sent to the requesting provider.
If the information for our members ages 20 and under is not provided to us within seven calendar days of the date the letter is sent to the member, we will send notice to the member informing them of the denial of the requested service due to the incomplete information. The member will have an opportunity to appeal.