Medical Policy
Effective Date:03/22/2004 Title:Procedures Requiring Pre-Authorization
Revision Date: Document:BI025:00
CPT Code(s):
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    QualChoice maintains a list of procedures currently requiring pre-authorization.  This list is provided to participating health care professionals, who are responsible to obtain pre-authorization for their patients. 

2)    When our members seek care out of our network, they should check whether the benefit requires pre-authorization and the benefit payable for any service they anticipate receiving from an out of network health care provider. This information can be obtained by calling Customer Service (at the number on the membership card) or by going online to www.qualchoice.com.
Medical Statement

The Preauthorization list is separately maintained, but is attached to this policy. If this hot link does not function, please log on at www.qualchoice.com.
Limits
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Reference
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Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.