Prior Authorization

A prior authorization (PA) is an approval from Healthy Blue to get some services — before you receive them. Your PCP or specialist will ask us for this approval when one is required. This is to make sure that we cover the services before you get them.

A PA means that both Healthy Blue and your doctor agree that the services are medically necessary.

Medically necessary services are services the state Medicaid program covers, including any treatment limits. When a service is medically necessary and is a covered benefit, Healthy Blue will pay for it as long as you are eligible.

Getting an approval will take no more than 14 calendar days. If urgent, it will take no more than 72 hours.

We may not approve the service you or your PCP asks for. We’ll send you and your PCP a letter telling you why we would not cover the service. This letter is called an adverse benefit determination. The letter also will let you know how to appeal our decision. If you have questions, you or your PCP may call us.

Here are some services that may require approval from us:

• Audiology (hearing services).
• Behavioral health and substance use disorder services.
• Home health care.
• Hospital inpatient services.
• Long term care.
• Some labs and X-rays.
• Some transportation services.
• Certain prescription drugs and medicines.
• Some therapy services (physical, occupational and speech).

Getting a decision will take no more than 14 calendar days. Healthy Blue may extend the decision time frame by up to an additional 14 calendar days if needed.

Urgent Preservice Requests

Getting a decision will take no more than 72 hours. There are certain situations where the urgent timeline. may be extended:

• If Healthy Blue needs more information, we may extend the time frame to get the necessary information.
• The request does not meet the criteria for an expedited/urgent request.

If the request does not meet the requirements, it will be treated as a standard request and will be reviewed within 14 calendar days.

For all preservice requests, you, your authorized representative or your provider may request an extension. You should call the provider who ordered the treatment or call Customer Service to request an extension of an authorization.

If Healthy Blue extends the time frame, we will send you a letter with the reason for the extension and tell you about your right to file a grievance if you disagree with the decision.

How We Decide What To Cover

Healthy Blue wants to make sure our members get the medical services they need to get or stay well. To

do so, we have to decide which services we will cover. We call this process utilization management (UM). We work with local doctors and other health providers to decide which services are needed and proper for us to provide full coverage for our members. Medically necessary services are the services covered by the state Medicaid program, including any treatment limits.

You and your PCP always decide what is best for your health. If your doctor asks us to approve payment for certain health care services, we base our decision on two things:

• If the care is medically necessary.
• The health care benefits you have.

You also should know Healthy Blue does not pay Medicaid doctors or other health care workers who make UM decisions to:

• Deny you care.
• Say you do not have coverage.
• Approve less care than you need.

Sometimes we ask other companies that are not part of Healthy Blue to help us decide if care is proper. Some examples are those who are experts in the use of X-rays and other imaging services. If you or your doctor has questions about our UM program, call us at 866-781-5094 (TTY: 866-773-9634).

Continuity Of Care

Sometimes, we may allow members to keep getting treatment at no cost with a health care provider who is not in our network. This can happen when:

• A member is new to Healthy Blue and already getting care from a health care provider who is not in the Healthy Blue network.
• A member is getting ongoing treatment from a provider whose contract has ended with Healthy Blue for reasons that are “not for cause.” These are reasons that are not related to quality of care or compliance with other contract or regulatory requirements.

When this happens, Healthy Blue will:

• Let new members get ongoing treatment from a health care provider who is not in our network for up to 90 calendar days from the date the member is enrolled in Healthy Blue.
• Let new members in the first trimester of pregnancy who are getting medically necessary covered prenatal services keep getting these services without prior approval and regardless of the provider being in or out of our network. We may move members to a network provider if doing so does not.
• Affect services. Medically necessary prenatal services include prenatal care, delivery and postnatal care.
• Allow new members in their second or third trimester of pregnancy who are getting medically necessary.
• Cover prenatal services to keep getting these services with the prenatal care provider through the postpartum period.
• Set up continuity of care for members in an active treatment program with a provider whose contract has ended with Healthy Blue.