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Prior Authorization

Tools & Resources

Prior Authorization

The Right Care at the Right Time

Presbyterian Health Plan, Inc., and Presbyterian Insurance Company, Inc., (Presbyterian) want our members to get the best care in the best place, at the right time. One of the ways we do this is by using a prior authorization process. Prior authorization is part of our Utilization Management Program.

This program helps make sure that the services our members receive are medically necessary. This means that the care you receive is needed to diagnose, treat, or prevent medical conditions. It also helps make sure that medical facilities, such as hospitals, are being used the right way.

Presbyterian does not reward or pay health care providers for not providing services or for issuing denials of coverage. Presbyterian also does not reward or pay healthcare providers for not referring you for care. Your providers and Presbyterian consider these factors when making decisions about your care:

  • Is the service or care covered by your health plan?

  • Is the service or care appropriate for your healthcare needs?

Below contains more information about Presbyterian’s prior authorization processes, including how to submit and check status of a prior authorization request and our Prior Authorization Guide for members.

What is prior authorization?

This means Presbyterian must approve the service or prescription 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 medical 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.

Member Medical Service Prior Authorization GuideAsegurado Guía de Autorización Previa

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.

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

For the most up-to-date formulary drug information access your Presbyterian Pharmacy Benefit information. Formulary drug coverage status and additional restrictions are listed in your plan’s formulary (drug list).

Clinical Review Criteria for Coverage for Centennial Care Plans: A list of drugs that have specific edits/requirementsClinical Review Criteria for Coverage for Large Group Non-Metal Plans: A list of drugs that have specific edits/requirementsClinical Review Criteria for Coverage for Individual and Family/Employer Group Metal Level Health Insurance Exchange Plans: A list of drugs that have specific edits/requirementsSpecialty Pharmacy & Medical Drugs Coverage

How do I submit a prior authorization request?

Depending on the type of service needed, your provider will submit this request on your behalf. If you need to submit the request yourself, you can use the form below.

Prior Authorization Request Form

How do I check the status of a prior authorization request?

The myPRES member portal allows you to quickly check the prior authorization status of all requests made by you or your provider/practitioner. If you have additional questions, please call us:

How do I appeal a denied authorization request?

You can submit a complaint online.

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.

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