Prior Authorizations
There are several factors that impact whether a service or procedure is covered under a member’s benefit plan. Medical policies and clinical utilization management (UM) guidelines are two resources that help us determine if a procedure is medically necessary. These documents are available to you as a reference when interpreting claim decisions.
Prior Authorization Code Lists
Use these lists to identify the member services that require prior authorization.
Digital Authorizations
Submit for medical or behavioral health inpatient or outpatient services. Tract authorization cases. Access the Authorization application from the Patient Registration tab in Availity Essentials.
Helpful Links
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Payments for services from a non-participating provider are generally sent to the member, except where federal or state mandates apply, or negotiated agreements are in place.