Understanding Prior Authorization

As you navigate your health care, it’s important to note there are certain medical services or provider visits that require prior authorization by Prevea360 Health Plan. These authorizations are required so our Medical Affairs team can review the medical necessity of the recommended service or visit and make sure you are getting the appropriate care.

Our printable information sheet will help walk you through whether you need a prior authorization. And you can print and keep it for future reference.

Out-of-Area Care

You do not need an authorization for urgent and emergency care if you are not able to return to the Prevea360 Health Plan service area for immediate treatment—and if the medical need is determined as such upon review.

Be sure you understand the types of care available to you and the Out-of-Area Coverage policy here at Prevea360 Health Plan before you leave town.

If You Need Urgent Care...
Urgent care should be received at the nearest appropriate medical facility unless you can safely return to the service area. Please contact Prevea360 Health Plan by the next business day after seeing an out-of-network provider.

When we receive a claim for the services, it will be reviewed to determine if the diagnosis or symptoms were urgent. If so, payment will be based on our maximum allowable fee. You will be responsible for any fees that exceed this amount.

If You Need Emergency Care...
If you are outside of the service area and require emergency care, call 911 or go to the nearest medical facility. Please contact Prevea360 Health Plan by the next business day after receiving any emergency treatment or an emergency admission to a out-of-network facility.

If you are admitted to a out-of-network facility for inpatient mental health services, we must be contacted within 72 hours of being admitted. Failure to contact us could result in your being financially liable for all services.

Follow-up Care
Follow-up appointments to an out-of-area urgent or emergency visit should be made with a Prevea360 Health Plan provider. If this is not possible, please contact your home primary care physician for a prior authorization to an out-of-network provider.

Calling the Customer Care Center at 877.230.7555 can also help you verify a provider in that area who is covered under our nationwide network.
Do I need a prior authorization?
Need help determining if a prior authorization is required for a service or office visit? Check out our Understanding Prior Authorization sheet.