Prior Authorizations - Arranging Your Care

There are some services that we must approve before you can get them.  This is called prior authorization.  You may have to pay when a service is provided without prior authorization.

There are doctors and nurses who work for us to help your doctor choose the best way to take care of you.  They make decisions about the care that is most likely to help you by using specific guidelines for medical decisions.  The guidelines are based on whether the service is medically necessary.

Medically necessary means that items or services that have been given or will be given to a patient are needed to treat a medical condition and are not mainly for the comfort of the patient, doctor or other health care provider.

Examples are:

  • To find the cause of an illness or treatment of illness or injury.
  • To help a body part that is not normal work better.
  • To prevent illness.
  • To help a patient meet the right growth and development levels.

If you need a service that must be approved by us before it is done, your doctor will call us to get an approval.

Our doctors and nurses will look at all the medical facts given by your doctor within certain time limits to decide if this service is the best way to take care of you. Our doctors and nurses make a decision on whether the care is medically necessary and appropriate for you.  There is no extra payment given to these doctors and nurses no matter what they decide about your care.  Doctors and nurses are not rewarded for reducing the amount of care approved.

Some of the services that need to be approved by us before you have them are listed below:

  • Hospital admission
  • The use of an outpatient unit in a hospital for a dental operations
  • The use of an outpatient unit in a hospital for certain medical operations
  • Medical equipment for your home
  • Nurses to come to your home
  • Physical therapy, occupational therapy or speech therapy
  • Cardiac rehab and pulmonary rehab
  • Some pediatric and adult dental services
  • MRI and CT scan (testing)
  • Using a doctor or other provider not in our network
  • Ambulance service, except for emergencies
  • Chiropractic services (authorization must be obtained by the chiropractic office, including the initial evaluation)
  • Hospice (care for the terminally ill or dying)
  • Nursing home or rehabilitation admissions
  • Surgery

There may be other services that need to be approved by us first.  Your PCP or other doctor must contact us to get prior authorization for certain services.  If you do not have approval from us before getting these services, you may have to pay the bill.

If you need to have tests or an operation, your doctor will call us to have the services approved.  We will suggest a place for treatment.

If a service is not covered under the plan, your doctor can ask us for an exception.  We do not guarantee that all exception requests will be approved or covered.

If we denied payment for a service that you already had, your doctor may ask for a “retrospective review” to change the decision.  A retrospective review is a detailed look by us at your records and information to determine if the services were necessary to keep you healthy.

If you are admitted to the hospital and your doctor feels that you may need more days of care, a “concurrent review” may happen.  A concurrent review is a detailed review while you are still in the hospital.  This is also done by us to determine if the services are necessary to get you healthy.

You may request a copy of the criteria for medical necessity on which the decision was based by sending a written request to:

West Virginia Family Health
PO Box 22250
Pittsburgh, PA 15222

When You Do Not Need a Referral

There are some special services that do not require a referral from your PCP.  You can go to any of our network doctors for the services listed below without a referral:

  • Obstetrical and gynecological visits (pelvic exams, PAP tests, mammograms, pregnancy care, woman care)
  • Chiropractor visits (prior authorization is required for additional visits beyond the initial consultation)

You can go to any doctor for family planning services, even if the doctor is not in our network.

You do not need a referral for behavioral health services including mental health care (depression) or drug and alcohol abuse.

Our goal is for you to be seen by the specialist that can best treat you.  If there are not two specialists in the list of our network doctors that can treat you, we will make arrangements with a specialist that is not on our list.  Your PCP can help you make the request for care outside of our list of network doctors.  If your request is denied by us, you may file a grievance.  Please see the section later in this handbook for steps to follow for filing a grievance.

If you have been seeing a specialist for an ongoing problem, the doctor can choose to be your PCP.  Please call Member Services at 855-412-8001; the TTY number is 711 or 1-800-982-8771 for help in getting your specialist to be your PCP.

Specialty Care Referral

Doctors that work with a certain area of medical care are called specialists.  Some types of specialists are heart doctors, skin doctors, or someone who does surgery.

If you need special care that your PCP cannot give you, your doctor may send you to a specialist.  This is called a “referral.”  Your PCP and the specialist will work together for your total healthcare needs.

If you go to a specialist without your PCP’s referral, you may have to pay the specialist’s bill.  If you have been seeing a specialist for an ongoing problem, you can ask your PCP to grant a standing referral to the specialist or the specialist can choose to be your PCP.  Please call Member Services at 855-412-8001; the TTY number is 711 or 1-800-982-8771 for help in getting your specialist to be your PCP or talk to your PCP about ordering a standing referral.

A specialist may send you to receive special services or tests.  Some of those tests and services also require a referral.

Examples of services and tests that require a referral are:

  • Angiograms
  • Bone Scans
  • Chemotherapy (Hospital)
  • Endoscopies
  • Nerve Conduction Testing
  • Sleep studies