Prior Authorization (Part C)
What is prior authorization?
Prior authorization is a process which must be completed before you get some services. Some services must get prior authorization, also called prior approval, before the plan will pay for it. Your doctor will make the request. You can make the request too. We will need medical records and notes from your doctor. Other information that shows why you need the item or service may be needed. Call your doctor if you need this information.
What services require prior authorization?
To get a list of services that require prior authorization, please contact Absolute Total Care at 1-855-735-4398. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. For out-of-network services you must get prior authorization. You do not need prior authorization for emergencies. Out-of-network urgent care or dialysis does not need prior authorization. If you need to get dialysis services outside of the network area, please call Member Services.
What is the process for getting prior authorization?
You may get prior authorization (or prior approval) by calling Absolute Total Care. Providers need to send prior authorizations through the web portal, by phone, or by fax.
If you ask for a "fast decision", you will be told if we approve the service within 72 hours after we get your request. This is what we call an "expedited review". All other requests will be handled within 14 calendar days. If we find that your health may be in danger, we will hurry your request.
We will tell you what we decide in writing or by telephone. In the case of an emergency, you do not need prior authorization.
Prior authorization is not a guarantee of payment. The plan has the right to review the service for medical need after you receive the services. You must be a current member with Absolute Total Care to receive services. Some services have limits. Some benefits have exclusions.
If you have any questions, call Member Services at 1-855-735-4398. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711.
Information on appeals:
Standard appeal: You have the right to appeal if you don’t agree with a decision we make about services or payment. We will review our decision and let you know what we decide. You will get a written answer on a standard appeal 15 calendar days after we get your appeal. Our decision might take longer if you ask for an extension or if we need more information about your case. We will tell you if we’re taking extra time and will explain why more time is needed. If your appeal is for payment of a service you have already received, we will give you a written answer within 60 calendar days.
Fast appeal: You will get an answer within 72 hours after we get your fast appeal. You can ask for a fast appeal if you or your doctor believe your health could be harmed by waiting up to 15 calendar days for a decision.
We will give you a fast appeal if a doctor asks for one for you or supports your request. If you ask for a fast appeal without support from a doctor, we will decide if your request requires a fast appeal. If we don’t give you a fast appeal, we’ll give you an answer within 15 calendar days.
How to ask for an appeal with Absolute Total Care
Step 1: You, your authorized representative, or your doctor must ask us for an appeal. Your written request must include:
- Your name;
- Your address;
- Your Absolute Total Care ID number;
- Your reasons for appealing; and
- Your medical records, doctor’s letter, or other information that proves why you need the item or service. Call your doctor if you need this information.
You can ask to see the medical records and other documents we used to make our decision before or during the appeal and a copy of the guidelines we used to make our decision, at no cost to you.
Step 2: Mail, fax, hand-deliver your appeal, or call us.
For a standard appeal:
Absolute Total Care (Medicare-Medicaid Plan)
Attn: Appeals and Grievances
7700 Forsyth Blvd.
St. Louis, MO 63105
Telephone: 1-855-735-4398 (TTY: 711)
Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.
If you ask for a standard appeal by phone, we will send you a letter outlining what you told us.
For a fast appeal:
Telephone: 1-855-735-4398 (TTY: 711)