Understanding medical authorizations and approvals
Have you ever been in this situation? Your doctor says you need a test or procedure, but it must be authorized by your health insurance company first. The news of needing services alone may cause some anxiety, but the thought that you might have to go through a process to get it authorized beforehand may cause you to break out in a full-blown sweat.
But it doesn’t have to be that way. Understanding the ins and outs of authorizations can help calm your nerves. Here's the good news — as long as you choose and use an in-network doctor, all that approval work will be done for you.
1.
What is a medical or drug authorization and why is it needed?
An authorization is a review that must be done in partnership with your doctor and health insurance company before certain services, procedures and tests can be done.
While your doctor's expertise and recommendations are extremely important to your treatment plan, your health insurance company must review to ensure it meets medical necessity criteria and is covered by your plan. Authorizations and approvals help your doctor and health insurance company come together to make sure your care is appropriate, timely and safe.
They also help avoid any unexpected medical bills that might happen if a procedure or service isn't covered. Plus, an authorization can help our team at Wellmark Blue Cross and Blue Shield provide support throughout your experience.
Need a status update on an authorization?
Wellmark members can check the status of an authorization in myWellmark®. You can even view your decision letter right away without waiting for it to come in the mail. Log in to get started.
2.
What are the different types of authorizations and approvals?
Here’s a rundown of the most common types of authorizations. Don't worry, your in-network provider will be able to select the appropriate type of pre-service review based on your needs.
- Prior approval determines whether a proposed procedure or treatment is medically necessary. For example, a heart transplant or knee replacement surgery.
- Notification is required before you’re admitted to a hospital, excluding emergency and maternity services.
- Precertification determines medical necessity for certain types of admissions, like to a skilled nursing facility.
- Prior authorization is specific to certain prescription drugs and drug-related treatments.
- Preauthorization is needed for radiology services, like Magnetic Resonance Imaging (MRI) or Positron Emission Tomography (PET) scans, done in an outpatient setting.
- Out-of-network referral is necessary when your treatment requires out-of-network care.
3.
What types of treatment require an authorization?
Each type of authorization has a comprehensive list of procedures, services or admissions that require authorization. If you have health insurance through an employer, it’s important to log in to myWellmark to check your specific benefits and authorization requirements.
4.
Am I responsible for doing an authorization?
As long as you choose and use a provider who participates in your network, they are responsible for knowing whether or not an authorization applies to your treatment. It’s best to always ask your doctor to make sure any necessary requirements have been taken care of before you’re treated. To find an in-network doctor near you, log in to myWellmark.
If you wish to use an out‑of‑network provider, ask whether they’ll submit any required authorization on your behalf and confirm it’s approved before you receive care. This can help you avoid higher out‑of‑pocket costs or a denial of coverage.
5.
About how long does a typical authorization take?
In general, authorizations take less than 15 calendar days. However, if the request is urgent, it may be handled in as little as 24 hours for Wellmark members in South Dakota and 72 hours for members in Iowa.
6.
What happens if an authorization isn’t completed for a service that requires it?
If you or your doctor don't complete an authorization when it’s required, you may have to pay more for your service or even cover the entire bill.
7.
Where can I go if I have questions about an authorization?
If you’re a Wellmark member, we’re here to answer your authorization questions. Always check your benefits before receiving services. To easily access your coverage manual, check your current authorizations and manage your health plan, log in to myWellmark.