What is a Prior Authorization and When Do You Need One?
You deserve high quality service and care you can trust. We're here to help make sure that happens. To do this, we review requests for certain medical and pharmacy services. You may have heard this process referred to as making “Coverage Decisions.” We call medical requests “Organizational Determinations,” and pharmacy requests “Coverage Determinations.”
Either you or your doctor can request approval for these services. As soon as we get a request to allow a service, we move into action. Our qualified, licensed clinicians (including doctors, Registered Nurses, and pharmacists) review the requests. Authorization is required for several reasons. A prior authorization allows Florida Blue to:
- Verify that the service requested is covered by Medicare and your Florida Blue Medicare health or prescription drug plan
- Review services to determine if care is medically necessary and appropriate for you
- Review services to ensure services are being provided by the appropriate doctor in a setting that is appropriate for you
- Confirm that ongoing and recurring services are effective and are actually helping you
We base our decisions on the latest guidelines and coverage criteria. Medicare requires us to review these requests within certain time frames. This way we all work together to ensure minimal delays or disruptions to your care or treatment.
Things to keep in mind when you request authorization
- Many specialists ask for a referral or authorization to treat you. This is part of their internal office process. Ask your primary care doctor or PCP to give you a copy of the necessary paperwork, even if they think you won’t need it. This is not a Florida Blue rule. But it will save you time in the long run.
- Depending how complex a procedure or treatment is, you may need additional approvals from us.
- We don’t tell your doctor(s) what tests to perform or how to treat you. But we don’t know what approvals may be needed until your doctor lets us know the details of your treatment plan.
- Make sure you or your doctor get all the necessary approvals before you receive the service. Otherwise, you may be responsible for all or part of the costs of the service.
- Talk to your doctor so you know all the details of what this service involves. Where will the service be performed? What are the names of the doctors who will perform the service? What treatments or medications will you need? Make sure you have everything approved ahead of time.
- Sometimes, in-network facilities use out-of-network care providers. For example, let’s say you need an outpatient procedure but you need anesthesia. The facility may use an out-of-network anesthesiologist. That could mean higher out-of-pocket expenses for that specialist’s services.
- Check the status of your request with us early, and often. Some treatments or procedures are highly specialized. If that’s the case, we may check medical necessity with a third-party expert. That might delay our decision.
- Health systems get complicated with many different parties involved. It’s always better to ask lots of questions and follow up with us to double-check everything is correct. We’re here to help you and we don’t mind you making sure you have the answers you need.
You expect the highest quality care available. We help protect you by making sure you get the treatment that's appropriate and effective for you.
Want more information about how we review these requests? Call Member Services at the telephone number printed on the back of your Member ID card. Or, log in to your member account at floridablue.com/medicare. Find this information in your Evidence of Coverage under “Forms and Resources.”
Quality you expect. Care you deserve.
Filed under: Medicare