Medical Benefit Preauthorization Requirements
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.
What treatments require preauthorization?
The following 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 (beginning 09/01/2020)
- 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?
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.
For services or treatments that require inpatient hospitalization, call EMI Health at 801-270-3037 or toll free at 888-223-6866.
For outpatient services, it is recommended that you submit preauthorization requests via fax; however, telephone preauthorization requests are also accepted. You can find the Outpatient Notification Form at https://emihealth.com under Provider Forms. Upon completion, you will receive a letter outlining the authorization information. Responses are not faxed to the provider.
For durable medical equipment or prostheses, submit a written request, accompanied by a letter of medical necessity to Preauthorization Department, EMI Health, 5101 South Commerce Drive, Murray, UT 84107.
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.
Preauthorization is not a guarantee of payment. Payment for preauthorized services is contingent upon eligibility and benefits at the time of service. All terms and provisions of the plan will apply, and any services in connection with a preauthorization approval that are exclusions or limited benefits will be reimbursed accordingly. Services 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.
View prescription drug preauthorization requirements here.