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.