Medical necessity and prior authorization timeframes and member responsibilities

Services requiring prior authorization

Prior authorization is a process though which Arkansas Blue Cross and Blue Shield approves a request for a covered healthcare service before the member receives the service from a provider. Prior authorization must be requested and approved before the member to receives services. If not, the claim will be denied. Arkansas Blue Cross and Blue Shield member contracts require prior authorization for the following:

• hospital services with anesthesia for complex dental conditions
• advanced diagnostic imaging
• in vitro fertilization and infertility
• applied 54 behavioral analysis
• durable medical equipment for which costs exceed $5000
• surgically implantable osseointegrated hearing aids
• prosthetic devices for which costs exceed $20,000
• corrective surgery for craniofacial anomalies
• reduction mammoplasty
• certain prescription medications
• most organ transplants
• admission to neurologic rehabilitation facilities
• some pediatric vision services
• enteral feedings
• gastric pacemakers
• gender reassignment
• bariatric surgery
• hospice
• home health

This list is not exhaustive.

Denial of services with prior authorization

Arkansas Blue Cross will authorize coverage if medical necessity is supported. However, a request for prior authorization, if approved, does not guarantee payment. A claim receiving prior authorization as a pre-service claim must still meet all other coverage terms, conditions and limitations. Coverage for any such pre-service claim receiving prior authorization may still be limited or denied if investigation shows that:

• a benefit exclusion or limitation applies
• the covered person ceased to be eligible for benefits on or before the date services were provided
• coverage lapsed for non-payment of premium
• out-of-network limitations apply
• any other basis specified in the policy applies to limit or exclude the claim.

If no additional information is requested, you will be notified of the determination in no later than two business days from the date the pre-service claim was received. Additional information regarding medical necessity and prior authorization can be found in the member contract.

Dental prior authorization

Prior authorization is a process required for specified dental procedures before they are performed. Typically the dental or healthcare provider will obtain this preauthorization for the insured, but it is your responsibility to ensure the preauthorization is obtained before the services are performed. Services that are not preauthorized when required are not payable by USAble Mutual Insurance Company and will be the insured’s responsibility.

Timeframes and required documentation for prior authorization requests

Requests for preauthorization of benefits should be submitted within thirty (30) days of the date of the initial diagnosis or exam. The dentist or healthcare provider or the insured must submit for the Company's review, x-rays, a complete treatment plan, and in some cases, more substantiating material such as a study model.