Medical Necessity and Prior Authorization Timeframes and Member Responsibilities
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Defines the payer's definitions of medical necessity, when prior authorization is required, member and provider responsibilities for obtaining prior authorization, and decision timeframes for authorization requests. Applies to Alliant Health members and their providers.
No material clinical or coverage changes in this revision.
Coverage Criteria
Inpatient hospital care requires prior authorization except for maternity care. When Prior Authorization is required, the member’s in-network provider must call the payer to obtain approval before services are provided. If the member chooses an out-of-network provider (or has a plan that uses the PHCS network), the member is responsible for calling for Prior Authorization. Failure to obtain Prior Authorization when required may result in claim denials and charges that are not eligible for payment.
Provider Actions and Requirements
Prior Authorization requirements and decision timeframes
Prior Authorization is required for certain services (for example, any kind of inpatient hospital care except maternity). In-network providers must call Alliant Health to obtain Prior Authorization; members who choose an out-of-network provider (or have PHCS access) must call themselves. Decision timeframes: emergency inpatient admission notification within 2 business days after services start or within 1 business day after conversion from observation to inpatient; non-urgent requests decided within 7 days of receipt; urgent requests decided within 72 hours of receipt.
- Example service requiring PA: any inpatient hospital care (except maternity).
- In-network provider responsibility: call Alliant Health for Prior Authorization.
- Out-of-network or PHCS: member must call for Prior Authorization.
- Decision timeframes: emergency admissions – notify within 2 business days after services start or within 1 business day after conversion from observation to inpatient; non-urgent – 7 days; urgent – 72 hours.
Obtain required prior authorization before providing services
If you need a service that requires prior authorization, comply with the payer’s requirement to request authorization before providing the service; failure to do so may lead to claim denial and non-payment.
- Prior Authorization must be obtained before the service when required.
- Charges are not eligible for payment if Prior Authorization was not obtained and the service is thus not a Covered Service.
How to request Prior Authorization
In-network providers must call Alliant Health to request Prior Authorization using the number on the member ID card or (800) 865-5922. If the member chooses an Out-of-Network provider (or has PHCS access), the member is responsible for calling Alliant Health to request Prior Authorization.
- Prior Authorization phone number: (800) 865-5922 (also on back of member ID card).
- In-network: provider calls for prior authorization.
- Out-of-network/PHCS: member must call for prior authorization.
Denial risk if Prior Authorization is not obtained
Failure to obtain required Prior Authorization may result in denial of claims and charges not eligible for payment.
- Charges for services that are not Covered Services because Prior Authorization was not obtained are not eligible for payment.
Key Definitions
Background
Medical Necessity (or “Medically Necessary”) is defined as care that is reasonable, necessary, and appropriate based on evidence-based clinical standards of care. Prior Authorization (also called preservice review) is the payer’s approval process required for certain services to confirm medical necessity before care is provided. The Prior Authorization phone number is (800) 865-5922 and also appears on the back of the member ID card.
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