April 09, 2019
Prior authorization is a requirement that your physician obtains approval from SmartHealth to ensure that a health care service, treatment plan, a medical specialty prescription drug that is administered by a physician or durable medical equipment is medically necessary. There is also prior authorization for certain medications under the Ascension Prescription Drug Plan. This review helps to minimize costs and better manage your care.
The SmartHealth medical plan requires prior authorization for the following services:
All inpatient admissions to any acute/subacute care facility* require authorization and concurrent review. This requirement applies to all physicians and facilities, regardless of the provider’s network contract. (e.g. Ascension Network, National Network or Out-of-Network)
Admission to other inpatient facilities such as skilled nursing facilities, inpatient hospices, long term acute care hospitals and rehab facilities
Certain outpatient surgeries, treatments, services and durable medical equipment
High tech radiology (MRI & MRA) excluding Brain MRA, Brain MRI, Orbital and PET scans
All anesthesia and facility charges that are provided for dental care not covered by the health plan
*Examples of acute care and subacute facilities include hospitals, ambulatory care facilities, home health agencies, hospice, inpatient rehabilitation centers, among others.
It is your physician’s responsibility to request prior authorization, but it is ultimately your responsibility to ensure prior authorization is obtained.
Please note that prior authorization is provided pending benefits & eligibility on the date of service, experimental/investigational status, and is not a guarantee of benefits/payment.
You and your provider can access the Prior Authorization Form and details on submission on www.mysmarthealth.org in the Member Info/Provider Info Center.