About Prior Authorization

Prior authorization — sometimes called preauthorization or precertification — is a health plan cost-control process by providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage.

Frequently Asked Questions

The patient and the prescribing/rendering provider should receive a written response to a request for Prior Authorization/Program Exception (for a patient under 21 years of age) within 21 days. Regulation 1101.67 (relating to prior authorization) which requires a decision on requests for prior authorization within 21 days, does not apply to requests for program exception for a patient 21 years of age or older. If the patient and/or prescribing/rendering provider does not receive a written response, the patient or his/her representative may call the PA Recipient Hotline to request information on the authorization. The provider may call the provider inquiry unit to request information on the authorization or to check the status of a request. In either scenario, the number to call is 1-800-537-8862.

The MA 97: Outpatient Services Authorization Request From form is used to request a medical service/supply that requires prior authorization/program exception. You can download and print the the MA 97 Form or order it off of the MA 300X - Medical Assistance Provider Order Form. Instructions for completing the MA 97 request form, as well as where to mail the completed form are printed on the form.

Prior authorization is not required by an out-of-state facility when emergency services are provided in accordance with Regulation 1163.65. Prior authorization is required for "non-emergent/urgent out of state services" as per Place of Service Review Procedures on MA Bulletin 01-06-01; 02-06-01; 14-06-01; 31-06-01; 27-06-02. For questions related to services provided and billing, call the provider inquiry unit at 1-800-537-8862.

The following advanced radiologic imaging services require prior authorization review by calling 1-800-537-8862:

  • CT Scans, MRA Scans, MRI Scans, MRS Scans, Nuclear Medicine Cardiology Scans, PET Scans, and SPECT Scans.

Please refer to MA Bulletin 01-14-42 for more information.