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Prior Authorization

What is prior authorization?

This means Presbyterian must approve the service before you get it. These requests are approved or denied based on your benefits and whether the service is medically necessary (needed).

How do I know if a service needs a prior authorization?

Below are two links to a list of surgeries, durable medical equipment, orthotics and other items that need an authorization from the health plan before you can receive them. If you have questions regarding this list, please call the number on your member card.

An authorization is not required for emergency room and urgent care services. All out-of-network services require an authorization. Authorization requests are reviewed against rules (medical necessity criteria) to determine approval.

Disclaimers: Prior authorization approval does not guarantee payment. Coverage determinations and payment of claims depend upon eligibility, covered benefits, provider contracts and correct coding/billing practices. Cosmetic surgery that is solely for cosmetic purposes and not for medical necessity and experimental or investigational services are not covered benefits.

Prior authorization approval does not relieve the provider of responsibility to follow all applicable rules regarding the provision of services. This Prior Authorization Guide does not indicate coverage of benefits. Coverage is determined by the member’s benefit plan.