• Requesting a Prospective Review

    Request a prospective (or pre-service) review online with the Prospective Review Tool, or check status of an existing review. Requests also can be faxed using the Pre-service Request Form, or submitted over the telephone by calling Care Management at 877-342-5258 and following the prompts. This number is also for emergency reviews. 

    We require a fax of pertinent medical records to support a request. For a list of procedure codes requiring prior authorization, see the 2014 Prior Authorization Code List beginning on page 4. To see all codes requiring medical necessity review, see the Clinical Review Code List 

    Use our Prospective Review Tool to:

    • 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 

    Watch a quick demo to learn how to use the Prospective Review Tool (watch + listen)

    Prior Authorization

    Prior authorization is a contractual requirement for a patient or provider to obtain approval from a health plan in advance of certain services. For members with a plan subject to prior authorization, this pre-service review will be required to determine medical necessity and coverage for inpatient services and various outpatient services, supplies, and drugs.

    For a list of procedures and services that will require prior authorization, see the 2014 Prior Authorization Code List. To see all codes that require medical necessity review, see the Clinical Review Code List.

    Beginning Sept. 1, 2013, as groups enroll or renew, employer groups will move to prior authorization. Individual and small group plans will begin moving to prior authorization on Jan. 1, 2014. For more information, please see the Prior Authorization News Brief to Washington providers.

    Pre-Service Review (also referred to as Benefit Advisory)

    A pre-service review is used to determine if a service meets medical necessity criteria and if the member's plan includes the benefit. A pre-service review is not a requirement nor is it a guarantee of payment. If a pre-service review has not been requested for a service or procedure on the Clinical Review Code List, we will do a post-service (or retrospective) claim review before payment.

    Notification of Decision

    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 reference number; additionally we’ll 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.

    Requesting Changes

    If you have a change to a prospective review request, or need to notify us that a discharge notification was sent by mistake, please call Care Management at 877-342-5258.

    Extenuating Circumstances

    We recognize that there are extenuating patient situations that may make it impossible for providers to obtain a prospective review before treating a patient, or to notify Premera within the specified time period of a patient’s admission (for example: 24 hours). Contact Premera prior to submitting a claim and follow the recommended practices so that the claim will not be automatically denied. For more information, see Premera’s Extenuating Circumstances Policy