Most health plans have lists of services that are covered, lists of services that are not covered, and lists of services that might be covered if you meet certain requirements. Prior authorizations deal with that third type.
Now, I can’t speak for all health insurers, but if you have a WPS Health Insurance policy, here are some helpful hints surrounding when you may need to get a prior authorization.
Generally, prior authorization is required for specialized services. When you need care beyond the normal preventive variety, the WPS Medical Affairs staff, which includes doctors and nurses, wants to ensure that what your doctor is requesting is medically appropriate. These folks want to ensure you’re getting the best possible health care based on current research and medical best practices.
In many cases, your health care provider can handle the prior authorization for you. WPS takes requests from providers all the time. Ask your doctor how he or she handles prior authorizations to make sure you’re not duplicating your efforts.
Any time you are admitted to the hospital for an inpatient stay, you’ll need to get prior authorization. For non-emergency admissions, you have to let us know a minimum of three days prior to your elective admission. If you have an emergency admission, obviously you can’t let us know in advance. But most of our member certificates do ask that you contact WPS Member Services within two days of your emergency admission. That’s fair, right? As your health insurer, WPS needs to know what’s going on so we can support you and get your claims paid right away.
If you are a WPS member, I encourage you to review your benefits booklet for the specific requirements. You’ll also be able to find services and treatments there that may be excluded or have special referral requirements. If you have questions, you can always call the Member Services number on the back of your member ID card.