As you navigate your health care, it’s important to note there are certain medical services or provider visits that will require prior authorization by WellFirst Health. The process below will help walk you through whether you need a prior authorization. Services provided in an emergency room do not require a prior authorization. If you receive services without an approved prior authorization request, the claim may be denied if it is not found eligible for coverage. You may be financially responsible for the full cost of any service or drug for which prior authorization was not requested when required.
WellFirst Health requires these authorizations so our Utilization Management team can review the medical necessity of the recommended service or visit and make sure you are getting appropriate care.
Keep in mind, a prior authorization will not change the benefits under your plan. If a service is an exclusion of your plan, a prior authorization will not change the fact that the service is not a covered benefit.
If the services are covered under your plan, and you have an approved prior authorization, the services are subject to any applicable cost sharing (i.e. copays, co-insurance or deductibles).
To find out if a service is a covered benefit under your plan:
Some medical services require approval by WellFirst Health before you receive them. Our prior authorization process helps ensure you receive medically necessary care at the right time with the right provider. Your plan provider should submit prior authorization requests as soon as possible and prior to your scheduled services to ensure a determination can be made prior to their receipt. Standard requests have a turnaround time of 36 hours, including one business day.
Medical necessity means that the treatment, services or supplies from your provider or hospital are required to identify or treat your illness or injury. We will determine if they are:
Just because a doctor has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for an injury or illness doesn't mean that it is medically necessary.
If your WellFirst Health provider is recommending you see a physician or specialist outside of the our network, they must submit the prior authorization request for review. You’ll receive our determination by mail or you can call our Customer Care Center to check on the status of the prior authorization.
We recommend that you wait for a determination regarding your request before receiving services with an out-of-network provider. Be aware that you will be financially responsible for the full cost of any service with an out-of-network provider if the authorization your provider has submitted is denied.
If your provider recommends you receive a procedure or medical service, a prior authorization may be required. If it is required, your WellFirst Health provider is responsible for obtaining the approval before providing the procedure or service.
Your provider will help you coordinate the care you need. All plan providers have someone who works on acquiring authorizations for their patients.
To find out if a service or procedure requires a prior authorization:
When we receive a prior authorization request from your plan provider and if you reside in Missouri, we typically decide on requests for prior authorization for medical services within 36 hours including one business day for urgent and non-urgent requests. If the request is received while you are receiving a service, such as an inpatient admission (urgent concurrent request), the determination is made within 24 hours or as soon as the necessary medical information is received but will not exceed 72 hours. If the request is received after the service has been completed (post-service) the determination is made within 30 business days. Remember, even with a prior authorization, not all services are covered at 100%. You will be responsible for the co-pays and deductibles outlined in your Member Certificate.