When you need an authorization for a medical service, your doctor will submit a completed prior authorization form with pertinent medical notes attached (progress notes, laboratory and radiology reports, etc.). A patient may not request an authorization on their own behalf. Medical decisions are not influenced by financial considerations.
Criteria used for Authorization Decisions:
Member’s may obtain a free of charge copy of the actual benefit provision, guideline, protocol or other similar criterion on which an authorization decision was based, upon request, by calling Hill Physicians Medical Group Customer Service at 1-800-445-5747.
Authorization approval turnaround time
A decision to approve, modify or deny a service or treatment must be made within certain timeframes. These are based on the urgency of your medical condition and treatment needs.
For elective, non-urgent authorizations, most decisions are made within five business days of receiving necessary information from your physician to make the decision. Sometimes the doctor’s office does not send complete information, and the request will remain pending while we request additional information. This may take up to 45 days. If the request needs a higher level of review, our Medical Management team reviews the request. This can take up to 15 business days, but often happens much sooner.
For urgent authorizations, your provider may request an expedited review to be completed no later than 72 hours from receipt of authorization and pertinent information to make a decision.
Services that are urgent concurrent review, meaning they are reviewed as you are receiving on-going services, are reviewed within 24 hours of the hospital's request for approval.
You can contact your doctor’s office to find out when they submitted your request to Hill Physicians Medical Group or contact Hill Physicians Customer Service to inquire about the status of an authorization.
Reasons why authorizations are denied
While the vast majority of prior authorization requests are approved, there are times when medical services are denied. Medical services can be denied if they are:
- Not a covered benefit under your health plan.
- Not medically necessary according to medical guidelines (Hill Physicians, MCG, health plan, Medicare).
- Not a standard of clinical practice.
- Requested with an out of network provider/facility and may be available within your network.
Reviews are conducted by qualified medical professionals (doctors, nurses, pharmacists), but only doctors and pharmacists can deny or modify authorization requests.
Criteria used for authorization decisions
Member’s may obtain a free of charge copy of the actual benefit provision, guideline, protocol or other similar criterion on which an authorization decision was based, upon request, by calling Hill Physicians Medical Group Customer Service at (800) 445-5747.
More information on authorizations
Prior authorization is a process required for a provider to obtain advance approval before a specific procedure, service, device, supply or medication is delivered to their patient to qualify for payment coverage. Prior authorization is often referred to as “preauthorization,” “precertification” or “prior approval.”
Prior authorization approval is based on medical necessity, medical appropriateness and benefit limits. While Hill Physicians handles some authorizations, your health plan dictates others. Without this prior approval, your health plan may not pay for rendered treatment or service, leaving you responsible for the fees incurred instead.
Prior authorization is not required for medical emergencies. If you or a member of your family is having a life-threatening medical emergency, call 911 or go to your nearest hospital emergency room. As soon as possible after a medical emergency, it is recommended that you advise your primary care physician so that he or she may coordinate your continued care. Your health plan may also require that you notify them of emergency care.
We are happy to assist you and may even contact your plan to obtain detailed explanations of your authorizations.