Federal Marketplace/Exchange

Preauthorization

How we handle preauthorizations so you can best treat your patients

What is preauthorization?

Preauthorization is the procedure for confirming, prior to the rendering of care, the medical necessity and appropriateness of the proposed treatment, and whether (and if so, to what extent) such treatment is a covered benefit for the covered person. Whether preauthorization is required, and if so, how and when it must be obtained, depends on the kind of treatment and whether the provider is a participating provider or a non-participating provider.

What treatments require preauthorization?

  • · Hospitalizations and inpatient facility admissions, including skilled nursing facilities and mental health and drug/alcohol treatment

  • · Residential treatment

  • · Surgeries in a hospital or ambulatory surgical facility, including injectables and infusions

  • · Major diagnostic tests

  • · Capsule endoscopy

  • · Skin substitutes

  • · Home health services, including home I.V. services

  • · Dental services, including orthodontics, when dental injury occurs as a result of an accident

  • · Durable medical equipment and prostheses

  • · Hyperbaric oxygen treatment

  • · Clinical trials

  • · Flight-based inter-facility patient transport services when using a non-participating air ambulance service

  • · Unlisted, temporary, or supplemental tracking codes

How do I obtain preauthorization?

If you use a participating provider for any of the above treatments or procedures, the provider is responsible for preauthorization. You are advised to verify with the physician that preauthorization procedures have been followed.

If you use a non-participating provider for any of the above treatments or procedures, you are responsible for obtaining preauthorization, and benefits may be denied or reduced if you fail to timely obtain preauthorization, as follows:

  • · To obtain preauthorization for durable medical equipment or prostheses, submit a written request to EMI Health at 5101 South Commerce Drive, Murray, UT 84107, and include a description of the medical necessity and the expected length of time that the equipment will be required.

  • · To obtain preauthorization for all other services, call (801) 270-3037 or toll free at (888) 223-6866.

  • · For services or treatments that require inpatient hospitalization, other than emergencies, you or a designated family member must obtain preauthorization at least 48 hours prior to receiving the services or treatments, or as soon as reasonably possible.

  • · For emergency hospitalizations, you or a designated family member must give notice of the hospitalization within 48 hours after the covered person's condition has been stabilized by calling one of the phone numbers listed above.

What happens if I do not obtain a necessary preauthorization?

If you are responsible for obtaining preauthorization (i.e., you are using a non-participating provider), and you fail to do so in the required time, EMI Health will review the treatment and apply the following penalties:

  • · If the treatment is deemed not medically necessary and appropriate, benefits will be denied.

  • · If the treatment is deemed medically necessary and appropriate, benefits will be reduced by 50 percent.

  • · Any amount paid out-of-pocket for failing to follow preauthorization requirements is not applied toward the out-of pocket maximum.

Which prescription medications require preauthorization?

  • · Cialis, Levitra, sildenafil, Viagra (excluded for erectile dysfunction)

  • · Cystic Fibrosis

  • · Finasteride, Proscar (excluded for hair loss)

  • · Hepatitis C

  • · Inflammatory Conditions

  • · Multiple Sclerosis

  • · Narcolepsy

  • · Opioids in excess of seven days

  • · PCSK9s

  • · Substance abuse

  • · Medications listed as not covered on the plan's formulary

  • · Any medication exceeding $2,500 in cost

  • · Any compound medication exceeding $200 in cost

How do I initiate a preauthorization?

To initiate a preauthorization for a prescription, the prescriber must request the preauthorization using one of the following methods:

  • · Call EMI Health at 800-662-5851.

  • · Fax medical records to EMI Health, attention Pharmacy Review, at 801-269-9734.

  • · Use an online prior-authorization vendor such as Cover My Meds.

Important note

Preauthorization is not a guarantee of payment. Payment for preauthorized services and/or prescriptions is contingent upon eligibility and benefits at the time of service. All terms and provisions of the plan will apply, and any services and/or prescriptions in connection with a preauthorization approval that are exclusions or limited benefits will be reimbursed accordingly. Services and/or prescriptions that are exclusions of the policy will be denied; services that have plan limitations will be paid according to those limitations.

For more information, or if you have questions, contact our provider assistance team at 801-262-7975 or toll free at 800-644-5411.