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.

How do I verify if preauthorization or medical review is required?

Verify member’s network, then Search by CPT code to see if preauthorization or medical necessity review is required. PLEASE NOTE: If the incorrect network is selected, incorrect information will display. It is essential that the correct network is selected to receive accurate information.

What treatments require preauthorization?

  • · Hospitalizations and Inpatient facility admissions, including observation care over 48 hours, 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 medical services preauthorization?

The preauthorization process begins with a review for medical necessity. After medical necessity is determined through the Utilization Review and Case Management Unit, EMI Health finalizes the authorization by verifying patient eligibility, plan exclusions, COB information, plan maximums, etc. Upon completion, an authorization number is assigned, and a letter is sent to both the provider and the covered person outlining the authorization information.

All providers (except Cigna providers):
Initiate preauthorization here.

Cigna providers (outside of Utah):
Call 1–866-494-4872.

For durable medical equipment or prostheses, please fax the Outpatient Notification Form, along with supporting clinical, DME prescription, and Letter of Medical Necessity to 801-270-3010 or call 801-270-3037 or 888-223-6866(toll free) to begin the review process.

What happens if I do not obtain a necessary preauthorization?

If a claim is submitted without the required preauthorization, or if the claim submitted does not match the existing preauthorization information, processing may be delayed until EMI Health completes further review. If the appropriate preauthorization was not obtained, penalties will be applied in accordance with the Provider Participation Agreement.

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 for a pharmacy medication?

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.