Authorization and Medical Necessity — Provider Requirements

Prior authorization may be required when the member's benefit plan requires it or when indicated elsewhere in this policy. Services must meet medical necessity criteria and be supported by documentation in the medical record. Obtain authorization prior to rendering services when the plan requires prior authorization; failure to obtain required authorization may result in denial or reduced payment. Ensure documentation clearly describes the clinical indication, procedures performed, relevant diagnostic findings, and rationale linking services to medical necessity.

• Verify member eligibility and plan benefits before scheduling services; check for plan-specific prior authorization requirements and any time limits.
• When prior authorization is required: include clinical history, relevant diagnostic test results, supporting imaging or pathology reports, and proposed treatment plan in the request.
• Document medical necessity: state the diagnosis, symptoms, prior conservative treatments (when applicable), and objective findings that justify the service.
• Maintain contemporaneous medical records that fully support billed CPT/HCPCS codes; progress notes, orders, and results should be available on audit.
• If services are denied for lack of authorization or insufficient documentation, the provider may be responsible for payment; timely appeal processes should be followed per payer instructions.
• Bill using appropriate, industry-standard CPT, HCPCS, and revenue codes; include modifiers only when supported by documentation and coding guidelines.
• Do not bill services that are investigational, experimental, or not medically necessary per this policy—such claims are subject to denial and potential recovery.
• For retroactive authorizations or policy exceptions, submit documentation as directed by the payer; approvals are not guaranteed and may be limited to specific dates of service.