Prior authorization is required for many services and procedures, such as hospital stays and some surgical procedures.

In general, in-network providers are responsible for obtaining prior authorization before providing these services to you. Before receiving these services, you may want to contact your health care company to verify that the hospital, physician and other providers are in-network providers and that they have obtained the required prior authorization. In-network facilities and providers cannot bill you for services if they fail to obtain prior authorization as required.

If you are using an out-of-network provider, you are responsible for obtaining prior authorization before you receive these services. Note: You must obtain prior authorization when an out-of-network provider intends to admit you to an in-network facility or refers you to other in-network providers.

To obtain prior authorization, call the number on the back of your ID card. This call starts the utilization review process. Once you have obtained the authorization, please review it carefully so that you understand what services have been authorized and what providers are authorized to deliver the services that are subject to the authorization.

The utilization review process is a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures or settings. Such techniques may include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, retrospective review, or similar programs.