Prior Authorization and Recommended Clinical Review (Predetermination)
This page provides the tools you need to help you determine coverage through Prior Authorization, Recommended Clinical Review and post-service reviews.
Eligibility and Benefits Reminder:
Check eligibility and benefits first to confirm membership, check coverage, determine if you are in-network for the member’s policy and determine whether Prior Authorization is required through Availity® or your preferred vendor.
Utilization Management
Utilization management is at the heart of how we help members access the right care, at the right place and at the right time. Learn about the types of utilization management reviews – Prior Authorization, Recommended Clinical Review and post-service review. Learn More
How to Request Prior Authorization or Recommended Clinical Review (Predetermination)
Review the process to submit requests for Prior Authorization and Recommend Clinical Review. Learn More
Prior Authorization Lists
Refer to the lists of services or drug codes that may require Prior Authorization. Learn More