Prior Authorization
Please note, failure to obtain authorization may result in administrative claim denials. PA Health and Wellness providers are contractually prohibited from holding any participant financially liable for any service administratively denied by PA Health and Wellness for the failure of the provider to obtain timely authorization.
Check to see if a pre-authorization is necessary by using our online tool.
Expand the links below to find out more information.
As the Medical Home, PCPs should coordinate all healthcare services for PA Health & Wellness participants. Paper referrals are not required to direct a participant to a specialist within our participating network of providers. All out of network services (excluding ER and family planning) require prior authorization. PCPs should track receipt of consult notes from the specialist provider and maintain these notes within the patient’s medical record.
Some services require prior authorization from PA Health & Wellness in order for reimbursement to be issued to the provider. See our Prior Authorization List, which will be posted soon, or use our Prior Authorization Prescreen tool.
Standard prior authorization requests should be submitted for medical necessity review at least five (5) business days before the scheduled service delivery date or as soon as the need for service is identified.
Authorization requests may be submitted by fax, phone or secure web portal and should include all necessary clinical information. Urgent requests for prior authorization should be called in as soon as the need is identified.
Please visit our Manuals, Forms & Resources page for our Prior Authorization forms.