Pay BillUnderstanding the Member Preauthorization Process
Prior to receiving a medical service or procedure, you may be required to obtain approval from your health insurance plan. This is known as “member preauthorization” and ensures that you are receiving safe, appropriate care. A detailed list of services requiring preauthorization is included in your contract (“Certificate of Coverage”).
How It Works
If you require a service on Independent Health’s member preauthorization list, you are responsible for obtaining approval by calling the Member Services Department at (716) 631-8701 or 1-800-501-3439. While your provider may also do this on your behalf, keep in mind that it is your responsibility to ensure preauthorization is obtained from Independent Health prior to receiving these services to avoid potential financial penalties.
The request for member preauthorization should be made 15 calendar days in advance of the service(s) being rendered, or within 48 hours of the first business day following emergency services and/or admission.
Independent Health will review the member preauthorization request, which may take 3 to 5 business days. Once a decision is made, you will be notified in writing of the decision.
EXAMPLE
STEP 1:
Kim goes to the doctor for abdominal pain. After a physical exam and subsequent blood work, the doctor diagnoses Kim with gallbladder pain and suggests surgery to remove the gallbladder.
STEP 2:
Kim calls Independent Health Member Services Department at least 15 days prior to her surgery date to request preauthorization for the procedure. To help us process her request, she obtained the following information from her provider before calling:- Requesting provider name, address and tax ID
- Place of service, address and tax ID
- Date of service
- Procedure name and code
- Diagnosis name and code
- Type of service
(e.g., inpatient, outpatient, home care, DME, radiology)
STEP 3:
Within 5 business days, Kim receives a letter in the mail with a response to her preauthorization request. Since her request was approved, Kim is all set to go in for her surgical procedure.Note: This scenario is for illustrative purposes only. Please check your plan benefits to confirm what services require member preauthorization.
The following services require member preauthorization:
- Assistive Communication Devices (ACD) for Autism Spectrum Disorder
- CAR-T-Cell Therapy
- Clinical Trials
- Continuous glucose monitoring devices, short term
- Durable Medical Equipment
- Customized items/equipment
- Electrical Stimulators
- Total electric Hospital Beds
- Jaw Motion Rehabilitation system and accessories
- Lift equipment/devices
- Negative Pressure Wound Therapy (Wound Vac)
- Non-standard wheelchair accessories
- Oral appliances for sleep apnea
- Power wheelchairs and accessories
- Wearable Defibrillator Vests
- Elective hospital/facility admissions to include but not limited to:
- Admissions for transplants
- Inpatient rehabilitation and habilitation admissions (Physical, Speech and Occupational Therapy)
- Inpatient Mental health admissions
- Medical admissions
- Skilled nursing facility admissions
- Substance use inpatient admissions
- Surgical admissions
- Extracorporeal Shock Wave Therapy (ECSWT) for Chronic Plantar Fasciitis
- Gamma Knife
- Gender Dysphoria – Surgical Treatments
- Genetic Testing
- Home Births
- Home Health Care Services excluding Home Infusion Nursing Visits
- Hyperbaric Oxygen Therapy (Systemic and Topical)
- Therapeutic Radiopharmaceuticals: Zevalin, Lutathera, Hicon, Xofigo
- Partial Hospitalization for Mental Health Services
- Partial Hospitalization for Substance Use
- Electronic Artificial Limbs
- Mental Health Residential Treatment
- Substance Use Residential Treatment
- Skin Substitutes
- Sleep Studies(Facility Based)
- Surgical Procedures:
- Back and Neck Surgery
- Bariatric Surgery (weight loss surgery)
- Breast Surgery: Implant Removal, non-cancer diagnosis Breast Reconstruction, Breast Reduction Mammoplasty (male and female)
- Cosmetic Procedures (medically necessary)
- Implantable Defibrillators
- Joint Replacements – Hips, Knees & Shoulders
- Oral Surgeries (Orthognathic)
- Percutaneous Left Atrial Appendage Occlusion e.g. Watchman
- Reconstructive Procedures
- Septorhinoplasty & Rhinoplasty
- Spinal Cord Stimulation
- Temporomandibular Joint (TMJ) Disorder
- Total Artificial Heart
- Transcatheter Aortic Valve Replacement (TAVR)
- Transplant Procedures
- Uvulopalatopharyngoplasty (UPPP)
- Varicose Vein Procedures
- Vagus Nerve Stimulation
- Wireless Capsule Endoscopy (WCE)
- Vision Therapy
Preauthorization list is subject to change at any time.
© Independent Health Association, Inc. IH31749
OA-6432-7000 REV1121 PR1121