Some services, medicines, or items need approval from Health Partners before you can get the service. This approval process is called prior authorization. “Prior authorizations” are sometimes referred to as “preauthorizations” or “precertifications” or “preapprovals” – they mean the same thing.

Examples include chiropractic therapy, permanent pacemakers, and some prescriptions such as Botox, Soliris and OxyContin.

For some services that need prior authorization, Health Partners decides whether a requested service, medicine, or item is medically necessary before you get the service. You or your provider must make a request to Health Partners for approval.

Note: Health Partners requires prior authorizations for some services that are performed in an outpatient/inpatient setting, including services performed in the office, short procedure units, ambulatory surgery centers, clinics, and hospital outpatient departments.

How to ensure that Prior Authorization has been requested

When a service, item, or medicine requires prior authorization from Health Partners before it can be provided to you, typically your provider will submit the prior authorization request with current doctor's orders and supporting clinical documentation through our online provider portal. Your provider may also fax the request to Health Partners Plans at 1-866-240-3712 or call in the request by phone at 1-888-991-9023.

Please talk to your PCP or specialist or call our 24-hour Member Relations line at 1-800-553-0784 (TTY line for the deaf or hearing/speech-impaired is available at 1-877-454-8477):

• If you are not sure that your provider has requested prior authorization
• If you are unsure whether prior authorization is needed for a service, item or medicine
• If you simply need help to better understand the prior authorization process

Member Relations can also help you find a doctor or get a listing of participating providers.

If you would like a copy of the medical necessity guidelines or other rules that are used to decide your prior authorization request, send a written request to:

Health Partners Plans
ATTN: Complaints and Grievances Unit
901 Market Street, Suite 500
Philadelphia, PA 19107

You can also call Member Relations at 1-800-553-0784 (TTY 1-877-454-8477) to request medical necessity criteria. Providers should call the Provider Services Helpline at 1-888-991-9023.

What Requires Prior Authorization?

Services that require prior authorization:

• All scheduled inpatient hospital admissions and acute rehab admissions
• CT scans, MRIs, PETs and certain other radiology services when received as an outpatient and not an emergency
• Durable medical equipment like wheelchairs, and hospital beds
• Medical oncology (chemotherapy) services
• Nurse visits and other home health services
• Physical/occupational/speech therapy

You may also need to receive approval or prior authorization to receive certain medications. The following kinds of medications may require prior authorization:

• Non-formulary medications or benefit exceptions required by medical necessity
• Medications and/or treatments under clinical investigation
• Medications used for non-FDA approved uses
• Medications that exceed $1,000 per claim
• All brand name medications when there is an A-rated generic equivalent available
• Prescriptions that exceed plan limits (day's supply, quantity or cost)
• Prescriptions processed by non-network pharmacies
• New-to-market products
• Medications that have treatment guidelines approved by our Pharmacy and Therapeutics Committee
• Orphan drugs
• Selected injectable products (self-administered and/or physician office administration)

Your Member Handbook

For more information regarding prior authorizations, including review timeframes, outpatient drugs, denials, program exceptions, etc., please review your Member Handbook.