Prior authorization is a process to review certain treatments, services or procedures. It’s required before a member can get certain tests, treatments, medication or supplies. We require prior authorization so we can make sure you’re getting the care you need. Services obtained by an out-of-plan provider/facility require prior authorization.
Referrals and prior authorizations
Your employees want to get the care they need when they need it. We make it easy.
HMO members
Referrals
With Health Alliance Plan, specialty office visits don’t require referrals from a primary care physician. But in some cases, the specialist may require a referral from a member’s PCP. Many specialists are booked out months in advance and may only accept patients whose PCP believes they need specialty care.
Prior authorization
Before a member goes to the doctor or have services performed, it's important to understand our approval process. There are common treatments and procedures that require approval before you get them. This is also known as prior authorization.
If their service requires prior authorization, their doctor will take care of it on their behalf.
Example:
When Mary visits the ear, nose and throat doctor for the first time, she pays her specialist office copay. After her consultation, the ENT recommends a sinus surgery for Mary. Before she has the surgery, the ENT’s office must get prior authorization from us to make sure the service is covered and that it’s medically necessary.
For hospital stays
For inpatient hospital stays, the member’s doctor will get prior authorization from us. Emergency room visits don’t require prior authorization. Members must notify us within 48 hours of the emergency admission.
Prior authorization metrics
Health Alliance Plan
To comply with the CMS Interoperability and Prior Authorization final rule, Health Alliance Plan of Michigan is required to annually report aggregated prior authorization metrics on our website. Specifically, this includes a list of all medical items and services (excluding drugs) that require prior authorization, as well as data on prior authorization requests for those items and services (e.g., approvals, denials, etc.) over the previous calendar year. Publicly reporting these metrics promotes transparency and accountability, helps patients understand prior authorization processes and enables providers to evaluate payer performance. In addition, metrics can be used to compare plans, programs and payers.
Alliance Health and Life Insurance Company
To comply with the CMS Interoperability and Prior Authorization final rule Alliance Health and Life, Insurance Company is required to annually report aggregated prior authorization metrics on our website. Specifically, this includes a list of all medical items and services (excluding drugs) that require prior authorization, as well as data on prior authorization requests for those items and services (e.g., approvals, denials, etc.) over the previous calendar year. Publicly reporting these metrics promotes transparency and accountability, helps patients understand prior authorization processes and enables providers to evaluate payer performance.
PPO members
Members with a PPO plan don’t need to worry about referrals. With a PPO plan, they have the flexibility to seek care from doctors in and out of the network. But they might pay more if they choose a doctor outside of our network.
Prior authorization FAQs
A member's doctor submits a request based on the recommended treatment. Then, they and their doctor will receive a notice of approval or denial within 7 days*. Their request must be approved before you accept treatment or services. If they are not approved, the member may be responsible for the entire cost of their care.
*FEHB members and some ASO members will receive notice within 15 days.
Based on the member's plan type, they can review prescription medications that require prior authorization at: hap.org/prescription-drug.
The member can view a summary of the services/procedures that require prior authorization from us either at: hap.org/clinical-criteria.
OR
They can log in at hap.org and select MyCare and then Referrals and Prior Authorizations.
If their request is denied, the member has the right to know why. Requests can be denied for various reasons. If the service is denied, the member will receive a letter that includes the rationale for the denial, along with appeal information. If they need more information, they can talk to their doctor or call the number on their member ID card.
If the member has questions about the prior authorization request process or their benefits and coverage, please have them contact Customer Service.
