Pre-approval: what it means for you and your care

For some benefits in your plan your doctor will need to get approval from us before you can receive treatment. This is called prior authorization or pre-approval. The process doesn’t take long – your doctor can request one online and oftentimes have a decision instantly. But if your doctor doesn’t get pre-approval when one is necessary, we may not be able to pay for that care.

Care that requires pre-approval

The need for pre-approval will depend on which plan you have. You can log in to MyHealth to check the Certificate of Coverage (COC)/Policy/Agreement section of your plan documents to see your exact benefits.

Some of the most common care that requires pre-approval is:

  • Inpatient hospitalization services
  • Select outpatient services like elective tonsillectomies and prostatectomies
  • Referrals to out-of-network doctors
  • Approval to travel far when you’re over 34 weeks pregnant
  • When medical equipment rentals or supplies (durable medical equipment) cost more than $1,000
  • High-tech radiology like PET scans, MRIs and CT scans, and nuclear cardiology studies

Patient education

Some pre-approval processes require that you use an online patient education support tool before you undergo certain care. This step ensures that you understand the risks of your upcoming procedure as well as the alternatives available to you.

Educating yourself before your appointment gives you the greatest chance of a quick recovery. Your doctor will give you more details and a link to Emmi®, an educational tool, when this applies.

Questions about your benefits?

Log in to your MyHealth account or contact us.