Prior authorization is the review of the medical necessity and appropriateness of selected health services before they are provided.
Review of the prior authorization criteria is completed annually.
The essential information required to initiate the PA process:
- Member name
- Member number or Medicaid number
- Member date of birth
- Requesting provider name
- Requesting provider’s National Provider Identifier (NPI)
- Rendering provider’s name
- Rendering provider’s National Provider Identifier (NPI)
- Rendering provider’s Tax Identification number
- Service requested - Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), or Current Dental Terminology (CDT)
- Service requested start and end date(s)
- Quality of service units requested based on the CPT, HCPCS, or CDT requested
If a prior authorization request is missing documentation to determine medical necessity and it will likely result in an Adverse Benefit Determination, the PA request must be limited to the PA requirements listed on the MCO’s website on the date the request is received.
Refer to the provider manual for more information regarding the prior authorization process.
Tips for requesting authorizations:
- Always verify member eligibility prior to providing services
- Complete the entire form and attach supporting documentation prior to submitting
The following are the prior authorization timelines:
- Nonurgent pre-service: For prior authorization of nonurgent care, a decision will be made within three (3) business days from date of request.
- Urgent/expedited pre-service: For prior authorization of urgent/expedited pre-service care, a decision will be made as expeditiously as a member’s condition requires and no later than 72 hours after receipt of the request.
- Urgent concurrent: For urgent concurrent care, a decision will be made within one business day – not to exceed 72 hours of receipt of the request for service or notification of inpatient admission.
- Post-service: For post-service care, a decision and notification is required within a reasonable period but no later than 30 calendar days from the receipt of the request.
- Post-stabilization: Within one hour for post-stabilization or life-threatening conditions, except for emergency medical conditions and emergency behavioral health conditions where prior authorization is not required.
- For a member who is hospitalized at the time of the request, within one business day of receiving the request for services or equipment that will be necessary for the care of the member immediately after discharge, including if the request is submitted by an out-of-network provider, provider of acute care inpatient services or from a member.
- Approval or Denial: Notification will be made no later than 24 hours after receipt.
- No response to PA request within 24 hours: A 72-hour emergency supply of a prescribed drug must be provided when a medication is needed without delay and prior authorization (PA) is not available.
Incomplete Prior Authorization Requests
An incomplete prior authorization (PA) request is a request for a service that is missing information needed to decide medical necessity. Parkland Community Health Plan will notify the requesting provider and member, by a phone call and in writing, of missing information no later than three (3) business days after the prior authorization receive date.
If any of the information is missing, illegible or incomplete, Parkland Community Health Plan will contact the provider by phone call and in writing to obtain the information necessary to resolve the Incomplete PA Request.
Parkland Community Health Plan uses the date that the complete request form is received to determine the start date for services. Previous submission dates with missing or incomplete information are not considered when determining the start date of service.
If the information requested is not received within three (3) business days from the date that the plan sent the notice to the provider and the PA request will result in an Adverse Benefit Determination -- Parkland Community Health Plan will refer the Incomplete PA Request to the Medical Director with all information received in the initial PA request. The determination should be completed within three (3) business days of the referral to the Medical Director.
Remember, a request for prior authorization is not a guarantee of payment. Unauthorized services will not be reimbursed.
To request an authorization, find out what services require authorization or check on the status of an authorization, visit our provider secure web portal. For more information about prior authorization, review your provider manual.
Need help with authorizations and more? Please call our Provider Customer Service at 1-888-672-2277 HEALTHfirst or 1-888-814-2352 KIDSfirst. Hours of operation are 8 am - 5 pm CST, Monday - Friday (except state holidays)