Preauthorization requirements
Some procedures must be approved before you head to the doctor. This helps us make sure you receive:
- The right treatment to meet your needs.
- Care by doctors in our network.
- The highest quality of care.
How does it work?
When care is performed or prescribed by an in-network provider, he or she may obtain preauthorization for you based on the requirements below.
If you use an out-of-network provider, you are responsible for making sure preauthorization requirements are completed. Your out-of-network provider may call us for preauthorization on your behalf.
If you are an HMO member, your primary care physician (PCP) is the only person who can call for preauthorization. You may not refer yourself.
Preauthorization requirements
To check preauthorization requirements for a specific service or procedure code, you may access the Single Source Preauthorization List.
Learn more about medical policies and preauthorization for specialized services.
For questions, or to check your preauthorization status, call 800.471.2242, Monday through Friday, 8:00 AM – 5:00 PM.
Preauthorization - Keystone Health Plan Central (KHPC)
Preauthorization - Capital Advantage Assurance Company® (CAAC)
Note: Investigational/experimental and cosmetic procedures are not eligible for coverage under most plans. To determine if a service is investigational/experimental or cosmetic, call 800.471.2242.