What is preauthorization?
Preauthorization is the process by which an HMO reviews the proposed treatment and tells you and your doctor how benefits may be paid. Generally, preauthorization care is paid at the highest level of coverage. You must obtain preauthorization for certain covered expenses such as a hospital stay. If you do not get the required preauthorization, your cost will be higher because the benefits payable by the plan will be reduced or the expenses will not be covered at all.
For certain services such as non-emergency hospital care, outpatient surgery, physical therapy, and home health care, your doctor will need to call Southern Health for preauthorization. Preauthorization is designed to ensure that you and your family receive the right care in the right place at the right time. A complete preauthorization list is provided to participating physicians and is also provided to you in your membership materials. As this list is subject to change, it is a good idea to confirm with Southern Health whether or not the service you will be receiving requires preauthorization.
Preauthorization is prospective review of a proposed healthcare treatment to determine availability of insurance benefits, medical necessity, and appropriateness. Sometimes it also includes assessment of the level of care and treatment setting. Certain medical services and prescription drugs require preauthorization in order to be considered for coverage under your plan. In those cases, your provider is to obtain preauthorization from PacificSource before the treatment is provided. Failure to preauthorize when required may result in you being held responsible for payment to your provider if the services aren’t covered by your plan.
