Services requiring preauthorization
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Preauthorization is when your provider sends a request for coverage of a service on the UMP preauthorization list, and the plan sends either an approval or denial of coverage. Some medical services and supplies require preauthorization by the plan to determine whether the service or supply meets the plan’s medical necessity criteria in order to be covered. The fact that a service or supply is prescribed or furnished by a provider does not, by itself, make it a medically necessary covered service.
Because your provider has the clinical details and technical billing information needed for the preauthorization request, it is to your benefit that they submit a preauthorization request on your behalf.
If services that require preauthorization are not approved before being provided, coverage may be denied. The plan does not approve or deny preauthorization for services that are not on the UMP preauthorization list.
Visit the Complaints and appeals procedures webpage to learn how to appeal the denial of a preauthorization request before receiving services.
For a list of services and treatments requiring preauthorization :
- Check the UMP preauthorization list.
- Call UMP Customer Service at 1-888-849-3681 (TRS: 711).
- Request a printed list by calling UMP Customer Service at 1-888-849-3681 (TRS: 711).
The UMP preauthorization list is updated throughout the year. The fact that a service does not require preauthorization does not guarantee coverage.
The information on this page does not apply to prescription drugs. For information on preauthorization for prescription drugs:
- Call Washington State Rx Services at 1-888-361-1611 (TRS: 711).
- Check the UMP Preferred Drug List (select your plan before you search).
- Find the coverage criteria for your drug.
- Read the ‘Preauthorizing drugs’ section in your certificate of coverage.
You will be notified in writing within 15 calendar days of the plan’s receipt of the preauthorization request whether the request has been approved, denied, or if more information is needed to make a determination.
If additional information is requested:
- You are allowed up to 45 calendar days from the date on the letter to submit the information requested.
- You will be notified in writing of the determination within 15 calendar days from either the plan’s receipt of the additional information or the end of the 45-day period if no additional information is received.
If you or your physician believes that waiting for a determination under the standard time frame could place your life, health, or ability to regain maximum function in serious jeopardy, your physician should notify the plan by phone or fax as a shorter time limit may apply.
“Preauthorization” is when your provider sends a request for coverage of a service on the UMP preauthorization list, and the plan sends either an approval or denial of coverage. If services that require preauthorization are not approved before being provided, coverage may be denied. The plan does not approve or deny preauthorization for services that are not on the UMP preauthorization list. Preauthorization is usually requested by the provider performing the services.
“Notification” means that your provider must contact the plan to let us know when you receive services. Notification is usually done by the facility at the time you receive these services.