My Account: Sign in Register Home Shop Plans & Services Already a Member? For Brokers For Providers News & Tips About What You Need to Know About Referrals and Pre-authorization February 23, 2021 While QualChoice does not require referrals, some services require pre-authorization (pre-approval). Find out ahead of time if the services you need call for a pre-auth. Your claim could be denied if pre-authorization was needed and you didn’t get it before you received care. Some services must be approved before you get them (called pre-authorization). The list of those services may change from time to time. Here are some examples: Being admitted to an inpatient facility or partial hospital unit Referral to an out-of-network provider if claiming in-network benefits Home healthcare or infusion services, hospice (inpatient or outpatient) Organ transplant services (inpatient or outpatient) Advanced imaging (performed as outpatient) Specialty medicines (Tier 5) Genetic tests (such as for diseases that run in families) Some prescription and specialty drugs must also be pre-authorized. They may be used only for certain diseases or require other drugs to be tried first. In-Network and Out-of-Network Pre-authorization If you use an in-network provider, they must get any needed pre-approval. If you’re traveling and using the QualChoice National Network, you must get the approval if it’s required. If you use an out-of-network provider, you must make sure they get the approval if it’s required. Know Ahead of Time Visit Services Needing Pre-authorization at QualChoice.com for all services that need pre-approval. Search for a service by name or click on a category in the Index. For prescription drug pre-auths, choose Medications. Click on the related Medical Policy for details. See your Coverage Policy or Certificate for more details. Tags: Using Your Benefits, Save on Healthcare Costs Categories: Members | Employers | Brokers Categories Brokers Employers General Members Providers Recent posts Preventing Flu Nov 9, 2021 08:24 Children Can Outgrow Weight Problems— With Some Healthy Changes Sep 21, 2021 11:04 Know Your Family’s Health History Jun 22, 2021 10:10 Protecting Dad's Health Jun 15, 2021 06:12 Best If Used By: Spring Cleaning Your Fridge May 25, 2021 10:38 View By Topic Affordable Care Act (ACA) - (3) Announcements - (34) Benefit Reminder - (7) COVID-19 - (9) CPC Plus - (8) Diabetes - (4) Group Plans - (6) Health IQ Challenge - (4) Health Tips - (105) Heart Health - (1) Immunization - (7) Improving Healthcare - (13) Individual Plans - (4) Maternity - (2) Medical Coverage Policy - (3) Medicare - (1) My Account - (11) News Release - (2) Open Enrollment - (4) Opioids - (1) PCMH - (7) Pharmacy and Drug Coverage - (4) Pre-authorization - (12) Prevention - (20) QCARE - (32) QualChoice in the Community - (1) QuicRewards - (6) Save on Healthcare Costs - (13) Security - (1) Stopping Tobacco and Nicotine Use - (14) Using Your Benefits - (13) Video - (35) QualChoice is committed to giving great customer service! Legal Notices Privacy Terms of Use Medicare Part D Notice Member Rights Your Right to Appeal Non-discrimination & Language Help About QualChoice About Us Contact Us Copyright © 2021 QualChoice. All rights reserved. | Site Map