Sometimes. Understanding your health plan's coverage is very important, there are different requirements for different plans. However, if you are having an health emergency, you do not need to get permission to access emergency care. Health plans do not require permission or authorization for a sick or wellness visit with a primary care provider.
Pre-authorization from your insurance company is different from but is in addition to the referral received from a Primary care doctor when you are part of an HMO. Pre-authorization is a decision by your insurance company that a health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary. Pre-authorization isn't a promise your health insurance will cover the cost, but, it is a means to help prevent unnecessary procedures and expensive brand name drugs from being prescribed when generics are available. Review your Summary Plan Description for more information about which services or supplies require pre-authorization.
Examples of health care services that require pre-authorization include:
- Planned admission to a hospital or skilled nursing facilities
- Inpatient and outpatient surgeries
- Advanced imaging, such as MRIs and CT scans
- Transplant and donor services
- Non-emergency air ambulance transport
- Medical equipment
- Drug treatments
To get pre-authorization:
- Health care providers usually initiate the pre-authorization request from your insurance company for you. However, it is your responsibility to make sure that you have pre-authorization before receiving certain health care procedures, services and prescriptions.
- Call your insurance company before you receive your health care services or prescription.
- Discuss the health care services or prescription that you need and ask if pre-authorization is needed.
- If you need prior approval, ask about the specifics. For example, know how many prescriptions or visits are approved, and if you need to be hospitalized, how many days are you allowed to stay.
If your insurance company doesn't grant pre-authorization, you can follow the insurance company's process for submitting an appeal to reverse their decisions.
To ensure that you get timely access to necessary medications, New Hampshire requires that prior approvals for prescription drugs take place within 48 hours. Beginning on January 1, 2015, New Hampshire law allows a pharmacist to provide a patient with a 72-hour supply of a prescription drug and invoice the insurance company for the emergency need.