Requesting a Review

  • Log in and use our Prospective Review Tool where you can:

    • Check if prior authorization is required or pre-service review is recommended
    • Submit a new review
    • Check the status of an existing review

     

    Launch Prospective Review Tool 

    The following requests are not currently available via the online tool, but can be submitted by fax via the linked forms below:

    Advanced imaging services on the AIM CPT Code List must be reviewed by AIM Specialty Health.

    For home health, orthognathic surgery, pharmacy reviewed drugs, and/or requests with more than 10 procedure codes, submit your request by calling Care Management at 800-722-4714, option 3. This number is also for urgent reviews. 

  • Pre-service review is recommended or prior authorization is required for major procedures or services that could be a health and safety issue for our members, such as most planned inpatient services, some planned outpatient services, some durable medical equipment, and some in-office pharmacy services including injectables, IVs, and biologics.

    The following non-exclusive list highlights some common services that require prior authorization:

    • Hospitalizations
    • Elective outpatient surgeries
    • Admission to a skilled nursing facility or rehabilitation facility
    • Non-emergency and elective air ambulance services
    • Some outpatient services
    • Organ transplants
    • Supplies, appliances, durable medical equipment (DME), and prosthetic devices over $500 (purchase)
    • Provider-administered drugs

    Emergency and dialysis services are not subject to prior authorization.

    See the Clinical Review by Code List for all codes needing review.

    Requests for reviews can be submitted:

    For Dental providers, the request should be faxed to Dental Review at 425-918-5956, or mailed to Dental Review, MS 173, P.O. Box 91059, Seattle, WA, 98111-9159.

    Note: We require a fax of pertinent medical records to support a request. For supporting documentation requirements, see the Clinical Review by Code List.

    We require providers to fax pertinent medical records to support a request. For supporting documentation requirements, see the Clinical Review by Code List.
    If a provider performs a service or procedure without prior authorization, the member may have to pay the full service cost or a share of the cost, plus an additional fee up to $1,500.
    If a pre-service review is not obtained, we will conduct a retrospective medical necessity review. If a provider performs a service or procedure without pre-service review, the member or provider may have to pay the full service cost.

    Our online Prospective Review Tool can help reduce your call wait times for submitting pre-service reviews. Providers can use this online tool to:

    • Check the status of an existing review,
    • Determine if a review is required or recommended, or,
    • Submit a review.

    Once you log in via the “Launch Prospective Review Tool” button, you’ll follow these easy steps:

    1. Member Tab: Enter the member information
    2. Date Tab: Enter date of service and place of service
    3. Codes Tab: Enter procedure codes (up to 10). Verify the code descriptions. If code requires review, select ‘Start Request.’
    4. Additional Info Tab: Enter the diagnosis code and select provider(s)
    5. Submit Tab: Enter contact information and submit review request
     

    The following requests are not currently available via the online tool, but can be submitted via the links below: 

    Advanced imaging services on the AIM CPT Code List must be reviewed by AIM Specialty Health.

    For home health, orthognathic surgery, pharmacy reviewed drugs, and/or requests with more than 10 procedure codes, submit your request by calling Care Management at 800-722-4714, option 3. This number is also for urgent reviews. 

    You can check the status of your pre-service review online using our Prospective Review Tool, even if you didn’t use the tool to submit it. The tool allows you to search by using either member ID or reference ID. (Note: At this time, home health, durable medical equipment, and urgent requests must still be submitted by fax.)

    Once a decision is made on a review request, you’ll be notified by fax or letter. Once prior authorization is obtained for a service or procedure, the authorization is typically valid for a minimum of 30 days (unless otherwise specified) or as long as the member is eligible.

    After 30 days, the clinical situation may have changed, so the provider should request a new review with updated and current clinical information. Providers should call and verify eligibility and benefits. Since eligibility varies by plan, please check the member booklet for details.

    Yes. And, depending on how you submit your request, here’s how you’ll be notified: 

    Prospective Review Tool: Once the request is submitted, the confirmation page includes a reference number and instructions for sending any supporting documentation.

    Phone: A reference number will be provided once information is entered into the system.

    Fax and email: A reference number will not be provided until the request is reviewed by our Care Management team.

    For dental providers, a reference number will be provided for dental reviews once information is entered into the system. The request should be faxed to Dental Review at 425-918-5956, or mailed to Dental Review, MS 173, P.O. Box 91059, Seattle, WA, 98111-9159.

    If an emergency exists that prevents you from obtaining prior authorization, Premera must be notified within 48 hours, following onset of treatment, or as soon as reasonably possible.

    We recognize there are patient situations that may make it impossible for providers to obtain a pre-service before treating a patient, or to notify Premera within 24 hours of a patient’s admission. In these situations, please contact us prior to submitting a claim and follow the recommended practices so that the claim will not be automatically denied. For more information, see our Extenuating Circumstances Policy

    If you have a change to a review request, or need to notify us that a discharge notification was sent by mistake, please fax the information to 800-843-1114.

    After we receive all required materials, our goal is to respond with a decision in a timeframe that meets or exceeds state and federal guidelines for timely review. If your review is urgent, please call us so we can help expedite your request.

    Once a decision is made on a pre-service review request, notification will be available via our Prospective Review Tool by entering the tracking number. We’ll also fax a decision to you. For any service being denied or approved as a prior authorization, a detailed letter will be mailed to you and the member. For urgent requests, we’ll notify you by phone.