Understanding Prior Authorization
At Providence Health Plan, we want our members to receive the right treatment, in the right setting, at the right time. There may be times when your doctor will need to contact PHP to request prior authorization for certain prescriptions, medical procedures or treatments. With prior authorization, our goal is to optimize the delivery of quality (safe, effective, affordable) health care and to provide excellent customer service.
What is prior authorization?
Prior authorization is a thorough medical- review process to ensure that certain drugs or treatments are prescribed appropriately. It is not required for all drugs or medical procedures – in fact, it affects only a relatively small number of medications and procedures. A panel of health care experts makes decisions about prior authorization, with extensive guidelines from evidence-based medical data and research.
It's important to understand that prior authorization is not meant to withhold treatment or only cut costs. Rather, it protects members from unproven or risky procedures, tests or medications that may be harmful and do not meet evidence-based guidelines as an effective treatment.
What if I've been denied?
We understand that prior authorization may be a frustrating process for members. If your prescription or medical procedure has been denied, talk to your doctor. You also can appeal PHP's decision by calling your Customer Service Team. We are committed to applying prior authorization fairly and with a focus on excellent customer service and quality. With prior authorization review, we can ensure that prescription drugs, medical procedures and treatments are provided based on scientific and expert medical guidelines.
Providence RN
Medical Advice Line where you can call 24-hours a day, seven days a week.