Utilization review and pre certification services Forms for Chicago
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FAQ
The healthcare provider is usually responsible for initiating prior authorization by submitting a request form to a patient's insurance provider.
In order to pre-approve such a drug or service, the insurance company will generally require that the patient's doctor submit notes and/or lab results documenting the patient's condition and treatment history.
If your health care provider is in-network, they will start the prior authorization process. If you don't use a health care provider in your plan's network, then you are responsible for obtaining the prior authorization.
Prior authorization (sometimes called preauthorization or pre-certification) is a pre-service utilization management review. Prior authorization is required for some members/services/drugs before services are rendered to confirm medical necessity as defined by the member's health benefit plan.
A health plan's precertification (or prior authorization) process usually begins with a nurse employed by the health plan completing an initial review of the patient's clinical information, which is submitted by the practice, to make sure the requested service meets established guidelines.
For example, services that may require pre-certification include outpatient and inpatient hospital services, observation services, invasive procedures, CT, MRI and PET scans, and colonoscopies. Patients are responsible for knowing the pre-certification requirements of their health plans.