Prior Authorization Guidelines
Some services, medicines, or items need approval from HPP 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.
For some services that need prior authorization, HPP 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 HPP for approval.
Examples of services that require prior authorization include physical therapy and some prescriptions.
Note: HPP 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 Prior Authorization Has Been Requested
When a service, item, or medicine requires prior authorization from HPP before it can be provided to you, your provider typically 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 HPP at 215-849-7096 or call in the request by phone at 1-866-500-4571.
Please talk to your PCP or specialist or call our 24-hour Member Relations line at 1-888-888-1211 (TTY 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 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 1-888-888-1211 (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?
Here is a list of 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)
For more information regarding prior authorizations, including review timeframes, outpatient drugs, denials, program exceptions and more, please review the KidzPartners Member Handbook.