About Prior Authorization


  • Providers can now use Availity to submit prior authorizations. Sign in to Availity or register and get training.

    To submit a prior authorization request, sign in to Availity. This tool considers the member's eligibility, coordination of benefits, and whether the member’s plan requires authorization or not. You can check the status of your request through Availity's Auth/Referral Inquiry tool or dashboard. If the request is denied, we’ll mail a detailed letter to you and the member.

    For training, visit Availity's Help & Training > Get Trained for step-by-step instructions and helpful screenshots.

    Check request status

    Ordering/servicing providers or facilities listed on the request (by NPI) can sign in to Availity to check request status through Availity's Auth/Referral Inquiry tool or dashboard. We typically respond to electronically submitted requests within 1-2 days, but it can take up to 3 days.

    You can also fax a request form to 800-843-1114. Be sure to include supporting documentation. See the code list for details.

    General prior authorization request
    Durable medical equipment (DME) request
    Provider-administered infusion drugs request 
    Out of network provider request form
    Transition of care

    Definitions:
    Transition of care: If a member is undergoing treatment, but their current provider isn't in the LifeWise network, they may be able to continue treatment or specific covered services for a limited time with their existing provider.

    Continuity of care: If a member is undergoing treatment, but their current provider is leaving the LifeWise network, they may be able to  continue to receive treatment or care for specific covered services for up to 90 days with the existing provider.

    Letter of agreement: A contract with an out-of-network facility or provider for specific services for a member. In-network benefits are provided for the services and the member isn't subject to balance billing.

    Benefit-level exception: An exception made to allow in-network benefits for services provided at an out-of-network facility or by and out-of-network provider. The member is still subject to balance billing.

    Note:     We typically respond to your original request within 5 calendar days. It may take up to 15 days if we need additional information. As soon as we make a decision, we'll fax it to you. If we deny the request, we'll mail a detailed letter to you and the member.

    You can change a review request by fax at 800-843-1114. Be sure to include the reference number.

    Types of services

    Advanced imaging, radiation oncology, sleep disorder management, genetic testing>

    Visit Carelon Medical Benefits Management (formerly AIM) or call 866-666-0776.

    Outpatient rehabilitation

    Visit eviCore healthcare.


    Admission and discharge

    View prior authorization details for admission and discharge notification.

    Common services that require prior authorization

    We require review for major procedures or services that could be a health and safety issue for our members. This includes most planned inpatient services, some planned outpatient services, some durable medical equipment, and some in-office pharmacy services including injectables, IVs, and biologics.

    Some common services that require prior authorization include:

    • All planned inpatient stays
    • Admission to a skilled nursing facility or rehabilitation facility
    • Admission to behavioral health residential treatment centers
    • Non-emergency and elective air ambulance services
    • Some outpatient services
    • Certain organ transplants
    • Purchase of supplies, appliances, DME, and prosthetic devices
    • Provider-administered drugs

    • Dental services such as:

      • Cosmetic and reconstruction services
      • Durable medical equipment
      • General anesthesia and facility services related to dental treatment
      • Intra-oral appliances for the treatment of sleep apnea
      • Orthodontic services for treatment of congenital craniofacial anomalies
      • Orthognathic surgery
      • Temporomandibular joint disorder (TMJ)
        •  

    Pharmacy

    Use our Rx search tool to see if a drug requires prior authorization.

    Emergencies and extenuating circumstances policy

    If an emergency prevents you from getting prior authorization, you must notify us within 48 hours following onset of treatment, or as soon as is reasonably possible.

    We know situations arise that may make it impossible for you to get prior authorization before treating a patient, or to notify us within 24 hours of admission. In these situations, please contact us before submitting a claim. Follow the recommended practices detailed in the extenuating circumstances policy so that the claim isn't automatically denied.

    On behalf of LifeWise, Carelon Medical Benefits Management (formerly AIM) is an independent company that manages imaging services for LifeWise.

    On behalf of LifeWise, eviCore healthcare is an independent company managing outpatient rehabilitation services for LifeWise providers.