Prior Authorization FAQs

What is a prior authorization (PA) request?
When and why is a PA needed?
How does a member obtain a PA?
My employee obtained a PA, why are they still being charged for the service?
When is a PA considered urgent?
I received a clinical referral. Do I still need to process a PA with Prevea360 Health Plan?


What is a prior authorization (PA) request?

A PA request is an extra step that is sometimes required before a member receives a specific service or procedure. A PA will not allow a service that is non-covered or a specific exclusion under the Member Certificate. For example, if cosmetic surgery is an exclusion of the policy, a PA will not change that benefit.


When and why is a PA needed?

Members can go to the Plan Benefits page or log in to view their member certificate or contact the Prevea360 Health Plan Customer Care Center to determine if the service or procedure requires a PA. For Network members, typically anything out of plan requires PA.

Some specific services require PA so that Medical Affairs can review the medical necessity of these services. Seeking services with non-plan providers/out-of-network will usually require PA.


How does a member obtain a PA?

A member must obtain a written authorization letter from Prevea360 approving the requested service or procedure to give to their provider. It is the member’s responsibility to secure written authorization approval before receiving treatment to ensure proper handling of the claim.


My employee obtained a PA, why are they still being charged for the service?

Obtaining a PA does not mean that services will be covered at 100 percent; members are still responsible for normal copays/deductibles/co-insurance amounts for any authorized services.


When is a PA considered urgent?

Authorization requests are not considered urgent only because of scheduling needs, they must be medically urgent to be processed more quickly than the standard 14 day or less timeframe.


I received a clinical referral. Do I still need to process a PA with Prevea360 Health Plan?

Yes. A clinical referral is different than an insurance authorization or referral. For example, an ENT doctor might require a referral from a family practice doctor to ensure patients are coming to them appropriately. If the ENT doctor is out-of-network, having a clinical referral to a specialist is not equivalent to an insurance authorization to receive those services.