Standard Prior Authorization

Prestige Health Choice is committed to a 48-hour turn-aroundtime on requests for prior authorization or pre-certification authorizations. Authorization responses will be sent via fax to the providers’ fax number(s) that are included on the authorization request form. However, by contract, Prestige Health Choice has up to 14 calendar days from receipt of request to determine whether a member’s request for non-urgent services is a medically appropriate and covered service.

An extension may be granted for an additional 14 calendar days if the member or the provider requests an extension or if Prestige Health Choice justifies to the Agency for Health Care Administration (AHCA) a need for additional information and the extension is in the member’s best interest. For members who voluntarily enrolled or who were automatically re-enrolled after regaining Medicaid eligibility Prestige Health Choice will honor any written documentation of prior authorization of ongoing covered services for a period of 30
business days after the effective date of enrollment or until Prestige Health Choice’s PCP assigned to that member reviews the member’s treatment plan, whichever comes first.

For mandatory assigned Medicaid members, Prestige Health Choice will honor any written documentation of prior authorization of ongoing covered services for a period of one month after the effective date of enrollment or until the PCP assigned to that member reviews the member’s treatment plan, whichever comes first.

Written documentation of prior authorization of ongoing services includes the following, provided that the services were arranged prior to the enrollment with Prestige Health Choice:

1. Prior existing orders
2. Provider appointments, e.g. dental appointments, surgeries, etc.
and prescriptions (including non-participating pharmacies).

Prestige Health Choice will not delay Service Authorization if written documentation is not available in a timely manner. Prestige Health Choice is not required to approve claims for which it has not received written documentation.

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