Understanding Health Plans Inc Prior Authorization for Medical Services

Health Plans Inc's prior authorization process is designed to ensure that you receive necessary medical services while controlling costs. This process involves a review of your treatment plan to ensure it meets certain criteria.

The review typically takes 2-3 business days, but can take longer in some cases. This timeframe may vary depending on the complexity of your case.

To initiate the prior authorization process, you'll need to submit a request to your healthcare provider, who will then forward it to Health Plans Inc. Your provider will need to provide detailed information about your treatment plan, including the medication or procedure you're requesting.

Your healthcare provider will work closely with Health Plans Inc to ensure that your treatment plan meets the necessary criteria.

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Prior authorization is a process where your primary care physician (PCP) or another provider asks for approval before you receive certain services. This is done to ensure that the services are medically necessary and meet certain criteria.

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Some services require prior authorization, including rented or purchased medical supplies and equipment that costs more than $250. This is to prevent unnecessary expenses and ensure that you're getting the most out of your health plan.

A prior authorization request is typically submitted by your PCP or provider, who will contact the health plan for approval. If the request is approved, you can proceed with the service.

If a prior authorization request is denied, you'll be notified and can ask for an appeal. If the appeal is not successful, you can request a State Fair Hearing.

Here are some examples of services that require prior authorization:

It's essential to review your member handbook for a current list of services that require prior authorization, as this list may change over time.

Requesting providers must initiate a request for prior authorization prior to delivering the requested service, medical supply equipment or clinician administered drug.

The timeframe for these requests is clear: a minimum of five business days before the desired start date of service should be allowed for prior authorization requests to be submitted.

This allows for a smooth and efficient process, giving providers and health plans ample time to review and determine the request.

When requesting non-urgent healthcare services, it's essential to plan ahead. Requesting providers must initiate a request for prior authorization before delivering the service.

You should submit prior authorization requests a minimum of five business days before the desired start date of service. This allows time for the request to be reviewed and approved.

Routine authorization determinations for Medicaid programs like STAR, STAR+PLUS, STAR Kids, and STAR Health typically take 3 business days.

For CHIP programs, the timeframe for routine determinations is a bit shorter, with approvals usually coming within 2 business days and denials taking 3 business days.

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In urgent or expedited situations, such as those involving CHIP and Medicaid, determinations are usually made within 72 hours.

Here's a breakdown of the timeframes for routine and urgent determinations:

To submit a claim, you'll need to review the address or electronic payor ID # on the back of your member ID card. For most members, claims can be mailed or submitted electronically to Health Plans, Inc. at PO Box 5199, Westborough, MA 01581.

You can also use the payer ID # 04271 for HPHC or # 44273 for WebMD to submit your claims electronically.

To submit a claim, review the claim submission address or electronic payor ID # on the back of the patient's member ID card.

You can mail or submit claims electronically to Health Plans, Inc. at PO Box 5199 in Westborough, MA 01581.

The address and payer ID may vary based on member-specific plans and networks.

You can also submit claims electronically using HPHC payer ID # 04271 or WebMD payer ID # 44273.

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To find HPI in your system, try searching for one of the following names: HEALTH PLANS INC, HPI, HARVARD PILGRIM HEALTH CARE – HEALTH PLANS INC, UNITED HEALTH CARE – HEALTH PLANS INC, THE CARE NETWORK – HEALTH PLANS INC, or HEALTH PLANS INC – EMPLOYERS HEALTH NETWORK.

Some systems also allow you to search by PO Box or Zip Code, so if that's an option for you, try searching for PO Box 5199 or the Zip code 01581.

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To notify inpatient admissions, you'll need to contact the relevant service area. There are specific phone and fax numbers for each area.

The Travis Service Area can be reached at 1-800-218-7453 or faxed at 1-877-650-6939.

Nueces Service Area can be contacted at 1-800-656-4817 or faxed at 1-877-650-6940.

Dallas and Fort Worth Service Area can be reached at 1-866-529-0294 or faxed at 1-855-707-5480.

El Paso Service Area can be contacted at 1-877-391-5923 or faxed at 1-877-650-6941.

Lubbock and Amarillo Service Area can be reached at 1-866-862-8308 or faxed at 1-866-865-4385.

Hidalgo Service Area can be contacted at 1-866-862-8308 or faxed at 1-877-212-6661.

Bexar Service Area can be reached at 1-866-615-9399 or faxed at 1-877-650-6942.

Medicaid and CHIP Rural Service Area can be contacted at 1-866-615-9399 or faxed at 1-877-505-0823.

For Behavioral Health Inpatient Authorizations (Medicaid), you can contact 1-844-842-2537 or fax 1-800-732-7562.

Here are the contact numbers organized by service area:

You can get covered services by calling your Primary Care Physician (PCP) when you need regular care. He or she will send you to see a specialist for tests, specialty care, and other covered services that they don't provide.

Some services don't require prior authorization, including direct access to in-network women's health specialists for routine and preventive health care services, emergency/urgent care, and well-child visits for children age 20 or younger.

You can find a provider using the online provider search tool, and when you've made your choice, call to set up an appointment. Remember to take your ID cards with you.

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Here are some services that require prior authorization:

If you're looking for services that don't require prior authorization, you're in luck. You can get direct access to in-network women's health specialists for routine and preventive health care services.

Emergency and urgent care services are also available without prior authorization. This includes non-elective, inpatient admissions that follow emergency services and stabilization of the patient.

Family planning services, such as routine check-ups and counseling, don't require prior authorization. However, your provider will keep your information private and won't share it without your consent, unless required by law.

Well-child visits for children under 20 years old don't need prior authorization. You can also get routine vision care without approval.

Here are some specific services that don't require prior authorization:

Dialysis services also don't require prior authorization. Sterilization services and termination of pregnancy services are not subject to prior authorization either.

If you're a Medicaid (STAR Health) provider looking to get prior authorization for orthodontic services, you'll need to submit your requests to the appropriate Dental Maintenance Organization (DMO) contracted with Texas Health and Human Services (HHS).

For routine requests, you have 3 business days to submit prior authorization requests for Medicaid (STAR Health) children. However, if the request is urgent or expedited, you'll need to submit it within 24 hours.

Here's a summary of the prior authorization notification timeframe for Medicaid (STAR Health) orthodontic services:

Prior authorization requests can be submitted by phone, fax, or online through the Secure Provider Portal. You can also contact Superior Member Services for assistance with prior authorization.

To submit a prior authorization request, you'll need to provide all essential information, including demographic and clinical information. This ensures that your request is thoroughly reviewed and processed.

The following services require prior authorization: Advanced Radiology Services, Ambulatory Surgery Center, Bariatric Surgery, Cardiology Services, Home Health Care Services, Hospice Admissions, Hospital Services Inpatient, Investigational and Experimental Procedures and Treatment, Laboratory Services, Long-Term Acute Care Hospital (LTACH), Medical Oncology Services, Neonatal intensive care unit (NICU)/Sick Baby Admissions, Obstetric Global Care, Orthotics & Prosthetics (O&P), Outpatient Services, Oxygen & Respiratory Services, Pain Management, Prescribed Pediatric Extended Care, Radiation Therapy Management, Select Outpatient Procedures, Skilled Nursing Facility Admissions, Sleep Diagnostics, Spinal Therapy and/or Surgery, Substance Use Disorder Services, Therapy (OT, PT, ST) Services, and Transplant Services.

If you need care from a provider who isn't contracted with Superior, you'll need to get prior authorization first. Prior authorization is required for all non-emergent health-care services, supplies, equipment, and Clinician Administered Drugs (CAD) delivered by a non-contracted provider.

The practitioner who orders or refers the service is responsible for initiating the prior authorization request. This ensures that the request is reviewed to determine if the care is medically necessary and can be approved outside of Superior's contracted provider network.

In cases where a contracted provider is available to deliver the requested service, the prior authorization request may be denied with redirection to a contracted provider.

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To request prior authorization, you can submit a request by phone, fax, or online through the Secure Provider Portal. You can also contact Superior Member Services for assistance.

Prior authorization requests must contain all Essential Information, including demographic and clinical information. Incomplete prior authorization requests will not be processed.

You can contact Superior Member Services at various phone numbers depending on your service area. For example, the Travis Service Area can be reached at 1-800-218-7453, while the Dallas and Fort Worth Service Area can be reached at 1-866-529-0294.

Prior authorization decisions for outpatient prescription benefits are finalized within 24 hours of receipt of the request. In emergency situations, a 72-hour emergency supply of a medication will be dispensed.

You don't need approval from Superior or your PCP for certain services, including routine vision care and well-child visits for children under 20. However, you will need to see a provider in Superior's network.

Some services require prior authorization, including advanced radiology services, ambulatory surgery center services, and home health care services. A full list of services that require prior authorization can be found in the table below.

To get covered services, call your primary care physician (PCP) for regular care. He or she will send you to see a specialist for tests, specialty care, and other covered services they don't provide.

You can use the online provider search tool to find a provider. Be sure to take your ID cards with you when you set up an appointment.

Your PCP must approve you to see a specialist. If they don't provide an approved service, ask them how you can get it.

Referrals are an essential part of navigating your healthcare needs. You may see any doctor in our network without a referral, but some doctors may request one from your primary care physician (PCP).

In-network providers will still cover medically necessary services without a referral. You can be referred to another provider if your PCP doesn't provide the care or service you need, or if you need to see a specialist.

You could be referred for medical tests, treatments, or other services. Some examples of referrals that don't require our approval include routine diagnostic tests, lab tests, basic X-ray services, and some routine care provided in a doctor's office.

Here are some examples of referrals that don't require approval:

Medicaid prior authorization requests must contain all Essential Information. This includes the necessary details to process the request efficiently.

To ensure your Medicaid prior authorization request is complete, make sure it includes Complete and Sufficient Clinical Information. This ensures the request is thoroughly reviewed and processed in a timely manner.

Here are the key components to include in your Medicaid prior authorization request:

Medicaid prior authorization requests must contain all Essential Information. This is a crucial step in the process, and it's essential to get it right.

To ensure your request is complete, make sure it includes all the necessary details, such as patient demographics and medical history.

Medicaid prior authorization requests must include Complete and Sufficient Clinical Information. This means providing detailed information about the treatment or service being requested, including diagnosis, treatment plan, and any relevant medical records.

Here's a breakdown of the essential information you'll need to include:

If you're dealing with CHIP, you need to understand the prior authorization procedures and requirements.

Demographic and clinical information is a crucial part of the CHIP prior authorization process. This information is typically required to determine the eligibility and coverage of a treatment or service.

Incomplete prior authorization requests can cause delays and complications in the CHIP process. It's essential to ensure that all necessary information is included to avoid these issues.

Here are the key components of CHIP prior authorization requests: