Prior Authorization Process

It is important for you to understand when you need an authorization and when you need a referral for care or services.

What is an Authorization?

An authorization is when your doctor must get approval from us before you can get certain care or medical services. Approval means that the care or service is medically necessary and will be paid for by your plan.

What is a Referral?

A referral is different. Your primary care doctor may send you to see a specialist(s) or to get certain care or medical services. We do not need to approve a referral. Your doctor starts the referral when she or thinks that specialist is medically necessary for your care.

Examples of When You Need an Authorization:

• Balance by CCHP and its participating medical group have certain procedures that will make the authorization decision within the time frame appropriate for your condition, but no later than five business days after receiving all the information (including additional examination and test results) reasonably necessary to make the decision. Decisions about urgent services will be made no later than 72 hours after receipt of the information reasonably necessary to make the decision.

• If the Medical Group needs more time to make the decision because it doesn’t have information reasonably necessary to make the decision, or because it has requested consultation by a particular specialist, you and your treating physician will be informed about the additional information, tests, or specialist that are needed and the date that the Medical Group expects to make a decision. Your treating physician will be informed of the decision within 24 hours after the decision is made by telephone or facsimile. The plan will notify the physician and the Member in writing within two business days of making the determination.

• If the Medical Group does not authorize all of the services, you will be sent a written decision and explanation within two business days after the decision is made. The letter will include information about your appeal rights, which are described in the “Grievance and Appeal Process” section of the Combined Evidence of Coverage and Disclosure Form. Any written criteria that the Medical Group uses to make the decision to authorize, modify, delay, or deny the request for authorization will be made available to you upon request. Once Balance by CCHP authorizes a specific type of treatment by a provider, it shall not rescind or modify the authorization after the provider renders the health care service in good faith.

View Our Prior Authorization Policy and Authorization Form

View Services Requiring Authorization and the Prior Authorization List