Prior authorization

Understanding prior authorization

As you navigate your health care, it’s important to note there are certain medical services or provider visits that will require prior authorization by WellFirst Health. The process below will help walk you through whether you need a prior authorization.

Why?

WellFirst Health requires these authorizations so our Medical Affairs team can review the medical necessity of the recommended service or visit and make sure you are getting appropriate care. Medically urgent authorizations, as determined by your physician, are handled as a priority. A good rule to remember is that any time you seek services with an out-of-network or nonparticipating provider, you will need to obtain a prior authorization from an in-plan provider.

For services provided by an in-network provider, your provider is responsible for obtaining prior authorization when required. For out-of-network providers, be aware that you will be financially responsible for the full cost of any service for which prior authorization is required if you fail to obtain prior authorization in advance of receiving care. Prior authorization requests should be submitted at least 15 business days prior to your planned procedure.

Is it covered?

Keep in mind, a prior authorization can only be obtained for services that are covered under your plan benefits.

For example, if bariatric surgery is an exclusion of your policy, a prior authorization will not change that benefit. If the services are covered under your plan, they are also still subject to any applicable cost sharing (i.e. copays, co-insurance or deductibles).

Getting prior authorization

Some medical services require approval by WellFirst Health before you receive the service. Our prior authorization process helps ensure you receive medically necessary care at the right time with the right provider.

Out-of-network physician or specialist

If your WellFirst Health provider is recommending you see a physician or specialist outside of the WellFirst Health network, your plan might require you have an approved authorization before your visit. If your WellFirst Health provider recommends you see an out of network provider, they must submit the prior authorization request for review. You’ll receive our determination by mail or you can call our Customer Care Center to check on the status.

Medical procedure or service

If your provider recommends you receive a procedure or medical service, a prior authorization may be required. If it is required, your Dean provider is responsible for obtaining the approval before providing the procedure or service. Some plans allow you to see a provider outside the Dean Health Plan network, but, in this case, if your provider fails to obtain a prior authorization you may incur a financial penalty.

Your provider will help you coordinate the care you need. All plan providers have someone who works on acquiring authorizations for their patients.

Steps to take

To find out if a service or procedure requires a prior authorization:

  • View your Member Certificate
  • Log in to the member portal
  • Call our Customer Care Center

Depending on your medical condition, it could take up to 14 days to obtain an authorization determination once it’s been submitted by your plan provider. And remember, even with a prior authorization, not all services are covered 100 percent. You will still be responsible for your normal copays, deductibles and coinsurance amounts.