When you’re sick, injured, or are in need of a procedure, more than likely, the last thing on your mind is whether your health insurance company will pay for it. You want to assume that the answer is a resounding “yes,” and in most cases, it is. However, before certain services, medications, and procedures are received or performed, health insurers require that these services, medications, and procedures are deemed medically necessary and delivered at the proper location. This process, called prior authorization, prior approval, or precertification, serves to protect members’ safety and well-being. Sometimes surgical procedures and medications do more harm than good, and health insurers go to great lengths to ensure that its members will benefit from them.
How Prior Authorization Works
At CDPHP®, our prior authorization process involves decision-making by medical professionals who base their determinations on two factors: the appropriateness of the service and the contractual relationship between our members and CDPHP. While our members can certainly contact us to have a service or medication approved, we encourage them to leave this task to their doctors, who will already have the necessary documentation our medical directors need to make a decision. Doctors can call the provider services department at (518) 641-3500, Monday through Friday, 7:30 a.m. to 5 p.m. to find out if a service requires prior authorization.
Once a decision is made, regardless of the outcome, CDPHP will notify the provider and the member in writing and over the phone. In some cases, when a service or medication is approved, we will ask the member’s doctor to inform the member of our decision. If we end up leaving a voicemail message for the doctor, we will also call the member. Our doctors and our staff are never encouraged or incentivized to issue inappropriate coverage denials.
While CDPHP members are always encouraged to use network providers, at times they may need a procedure or to see a specialist who’s out of network. In those cases, CDPHP requires a prior authorization before these services will be covered. Members should call us, or have their doctors call us, for approval before receiving any services to prevent claim denials.
Please note: Members with out-of-network benefits do not need a prior authorization to see an out-of-network provider, but they may need it for a certain service. Members should check their plan to determine whether it includes out-of-network benefits.
It Bears Repeating
Calling us before a service is performed cannot be emphasized enough: Certain services and medications must be approved before CDPHP, or any other health insurer, will cover them. If they are received before they are approved, members could be responsible for the full cost. In addition, the approval will ensure that the claims are paid on time.
Log In for More Information
For a list of services that require prior authorization from CDPHP, members can log in and click Medical Guidelines in the My Resources section on the right-hand side, followed by Explore Prior Authorization Guidelines, also on the right-hand side at the top of the page. The chart is organized according to plan type and service.
Members can also keep track of and check the status of their prior authorizations by clicking Medical Approvals in the right-hand column on their account home page.