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Prior Authorization

Prior authorization is the process of obtaining approval in advance of a planned inpatient admissions or rendering of an outpatient service. Prestige Health Choice will make an authorization decision based on the clinical information provided in the request.

Reasons for requiring authorization may include:

  • Review for medical necessity
  • Appropriateness of rendering provider
  • Appropriateness of setting
  • Case and disease management considerations

The prior authorization request should include:

  • The patient's diagnosis (ICD-9 and ICD-10 codes after October 1, 2015)
  • The CPT code describing the anticipated procedure

Providers may request prior authorization by calling Utilization Management at 1-855-371-8074 or by sending a fax request for authorization to 1-855-236-9285.

  • Pregnancy notification/OB global authorization - All OB care requires a global OB notification/authorization in order for proper and expedient payment to be made to OB providers. Once approved this authorization includes three OB ultrasounds, labor checks with place of service, all regularly scheduled pre-natal visits and all post-delivery follow up appointments. In addition, for high risk pregnancies, unlimited ultrasounds are allowed if provided by network Maternal/Fetal Medicine specialists.
  • For the member, this authorization initiates Prestige Care Management follow up from a team who works closely with pregnant members. The care management program has been developed specifically for these members to help ensure they are keeping up with all of their pre-natal and follow-up visits.
  • The pregnancy notification/OB care global authorization form can be faxed to Bright Start® maternity management at 1-855-358-5852.

Prior authorization forms

Pharmacy prior authorization forms