To be covered, some services require pre-authorization (pre-approval). Find out ahead of time if the services you need call for a pre-auth. Your claim could be denied if pre-authorization was needed and you didn’t get it before you received care.
Some services must be approved before you get them (called pre-authorization). The list of those services may change from time to time. Here are some examples:
- Being admitted to an inpatient facility or partial hospital unit
- Referral to an out-of-network provider if claiming in-network benefits
- Home healthcare or infusion services, hospice (inpatient or outpatient)
- Organ transplant services (inpatient or outpatient)
- Advanced imaging (performed as outpatient)
- Specialty medicines (Tier 5)
- Genetic tests (such as for diseases that run in families)
Some prescription and specialty drugs must also be pre-authorized. They may be used only for certain diseases or require other drugs to be tried first.
In-Network and Out-of-Network Pre-authorization
- If you use an in-network provider, they must get any needed pre-approval.
- If you’re traveling and using the QualChoice National Network, you must get the approval if it’s required.
- If you use an out-of-network provider, you must make sure they get the approval if it’s required.
Know Ahead of Time
Visit Services Needing Pre-authorization at QualChoice.com for all services that need pre-approval. Search for a service by name or click on a category in the Index. For prescription drug pre-auths, choose Medications. Click on the related Medical Policy for details. See your Coverage Policy or Certificate for more details.