Authorizations

Request Prior Authorization
Check Status of Prior Authorization

Instructions

Prior Authorization

  • For both Generations Advantage and US Family Health Plan members, Prior Authorization may be requested by the member's PCP or by the servicing provider/facility. 
    • Prior Authorization is not required for emergency care.

    • Prior Authorization requests should be submitted at least 14 calendar days prior to the date of service or facility admission.
       
    • If the servicing provider is not part of the Martin’s Point network, we require a letter of medical necessity (including clinical documentation) explaining why the service(s) can only be provided by this specialist. 
  • For mental health/substance abuse services call BHCP at 1-888-812-7335.
     
  • For outpatient therapy (PT, OT, ST, SLP), please submit a request using the Therapy section.
     
  • For prescriptions, please visit our Pharmacy page

Retrospective Authorization

  • US Family Health Plan: We will review retrospective authorization requests for all qualified care, before or after claim submission. Both participating and non-participating providers may submit online authorization requests.  

  • Generations Advantage: We will review retrospective authorization requests only under the following circumstances: 
    • Urgent/Emergent
    • Unable to Know
    • Not Enough Time
    For full descriptions please refer to the Provider Manual.

  • Please read the complete definitions of these exception criteria before submitting a retrospective authorization request. If your situation meets one of these criteria, please submit your request with documentation that supports the circumstance above. We will first assess the criteria for coverage and then for medical necessity.
     
  • Participating providers seeking retrospective authorization must file a claim for that service, wait for claim denial, and then submit an Authorization Dispute Form found in the Forms and Documents section. 

  • Non-participating providers seeking retrospective authorization must file a claim for that service, wait for claim denial and then initiate the claim appeal process on behalf of the member. We cannot begin the appeal process without a Medicare Appointment of Representative Form found in the Forms and Documents section. 

Forms And Documents

Additional questions? Read more in the Provider Manual or Contact Us.