Prior Authorizations

Prior authorization is required for certain medical services and prescription drugs .

Prior authorization processes for coordinated care plans may only be used for one or more the following purposes:

1. To confirm the presence of diagnoses or other medical criteria that are the basis for coverage determinations for the specific item or service; or
2. For basic benefits, to ensure an item or service is medically necessary based on standards specified in CFR § 422.101(c)(1), or
3. For supplemental benefits, to ensure that the furnishing of a service or benefit is clinically appropriate.

Reference: https://www.ecfr.gov/current/title-42/part-422#p-422.138(b)

View Prior Authorization Metrics.