Prior authorization process and submission checklist
An authorization answer is not a coverage, eligibility, or payment answer. Substrate does not submit prior authorization requests.
How to get prior authorization
This section is for a patient asking where to start. It does not say that every plan uses the same rule, and Substrate does not obtain the authorization.
- Identify the plan and product on the card.
- Ask that plan whether the service needs authorization. This page does not decide that.
- Gather what that plan’s instructions ask for.
- Use the plan’s official route, not a Substrate form.
- Keep the decision the plan sends.
How to submit prior authorization
This section is for a provider or biller. Submission stays on the plan’s official route. Substrate does not submit the request.
- Confirm the plan, product, setting, and service date.
- Open that plan’s current list or portal.
- Send the request only through the route that plan publishes.
- Record the reference number the plan returns.
- For a later change, use the renewal and setting sections on this page.
Checklist
- Plan and product name
- Member identifiers the plan’s own form asks for, kept out of this page
- Service, setting, and date
- Ordering and servicing providers
- The official list, form, or portal used
- The reference number and the decision, once the plan sends them
Renewals and changes
Expiration, an added visit, a provider change, and a service-date change stay on this page. This page does not give a universal renewal period. Contact the plan that issued the decision and follow its instructions.
Settings and network
Inpatient, outpatient, observation, emergency, site of service, and out-of-network care can differ. Keep them next to the plan’s own rule.
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.
The emergency sentence in that glossary is the glossary’s definition. It is not a determination for a specific payer.
Patient help
Can I submit my own prior authorization?
This page cannot tell you that. Use the plan’s official instructions. Substrate does not submit the request.
Language assistance
A Spanish version of this guide is not published. Use the plan’s official language assistance.