Know About Prior Authorization

Know About Prior Authorization

Prior authorization helps you get the most for your health care dollar. Registered nurses work with physicians to check and monitor medical services to help assure that you receive the most appropriate and cost-effective care for your condition. Only a physician can deny a prior authorization request.

Services that require Prior Authorization include, but are not limited to:

  • Inpatient hospital stays (except maternity admissions)
  • Skilled nursing facility
  • Rehabilitation facility admissions
  • Home health care (skilled nurse visits in the home, including home infusion)
  • Organ transplants
  • Certain outpatient surgeries and/or procedures, including:
    • Endometrial ablation
    • Panniculectomies (surgical removal of abdominal fat, "tummy tuck")
    • Varicose Vein surgery
    • Blepharoplasty (surgical removal of skin of the upper eyelid, "lift")
    • Tonsillectomy and Adenoidectomy under age 3
    • Tonsillectomy under age 3
    • Bariatric Surgery (if covered by your plan)
    • Breast Surgery for Augmentation and Reduction
    • 72-hour Ambulatory Glucose Monitoring
    • Neurobehavioral Status Exam/Neuropsychological Testing
    • Destruction of Cutaneous Vascular Proliferative Lesions (pediatric birthmarks) less than 10 sq. cm (laser technique)
    • Gastrointestinal Tract Imaging
    • Hysterectomy
    • Spinal surgery
    • Hip, knee, and shoulder surgery (not applicable to self-funded plans)
    • Pain management/spinal injections (not applicable to self-funded plans)
  • Certain specialty drugs
  • Certain prescription drugs (if covered by prescription drug benefit)
  • Advanced radiological imaging services (including MRIs, CT and PET scans and CT Angiography)
  • Durable medical equipment (DME) costing more than $500

Network providers in Tennessee will request prior authorization for you.

If you use providers outside Tennessee or out-of-network providers, it is your responsibility to request prior authorization by calling the number on the back of your member ID card.  Failure to request prior authorization may result in your benefits being reduced or denied, costing you more out-of-pocket.

Page Modified:May 18, 2012