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Authorization Requests: Determinations & Appeals

Determinations

A request for authorization is processed within 5 business days from the receipt of the request and all supporting clinical documentation. The process will be expedited for a medical condition that warrants immediate attention. Your physician should indicate the need for urgent or emergent review when medically necessary. Not obtaining authorization does not warrant an expedited review.

  • Once all documents are obtained the requested services will be reviewed for medical necessity and appropriateness, benefit exclusion or limitations, and for direction of care using specific criteria and plan guidelines.
  • After the determination is made, you will receive a notification in the mail. The requesting and/or requested physician/facility will receive the determination by fax.

Appeals

If a request for authorization has been denied, you have the right to appeal the decision. For more information on the appeals process and a more detailed description of the services that require prior authorization see the most current Plan Document (PDF).