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Authorization of Services

Getting the right services at the right place!

Simply Healthcare Plan works closely with your providers to ensure you receive the right care at the right place. We review the benefits offered by your plan when your provider is requesting a test or treatment you need to get better or stay healthy.

Prior Authorization- For certain tests or procedures, the plan requires your provider to obtain a prior authorization. This means approval must be obtained from the plan before you can have your test or procedure. Your primary care doctor is required to send in requests to the plan’s Pre-Certification department before scheduling your appointment. The request must contain all the information we need in order to make a decision. It is very important your doctor submit this request to the plan as soon as he/she has made the decision on the test or procedure you may need. The doctor must also send in any medical records or clinical information so that our nurses can review and make sure the test or procedure is a covered benefit and services are medically necessary.

Quick Authorization Form: The plan has identified select services that may be done without a prior authorization when performed at a doctor’s office, a free standing facility, or a diagnostic or ambulatory surgery center. All your doctor needs to do is check the right service you need to have done on the form and provide the form to you. Since these services do not require prior authorization, all you need to do is make your appointment with a participating provider. You are not required to have the form with you in order for the provider to service you.

Some services that do not require prior authorizations when performed at the provider’s office, free standing facility, diagnostic or ambulatory surgery center include:

  • X-rays, CT scans, Ultrasounds, Mammograms,
  • Select office procedures such as, fracture care, dermatology care and gynecology

Here is a list of some, not all, services that require prior authorization:

  • Inpatient admissions (except for emergencies)
  • Admission to any rehabilitation or skilled nursing facility
  • All surgical procedures, inpatient or outpatient
  • Chemotherapy
  • Hearing aids
  • Home health services
  • Medical equipment such as, oxygen, wheelchairs, CPAP machines
  • MRI’s, MRA’s, PET scans
  • Out of network services
  • Oral surgery
  • Pain management
  • Physical, occupational and speech therapy
  • Radiation therapy
  • Transplants

Emergency services do not require prior authorization.

Providers are encouraged to request services to be performed at locations other than hospital settings. These locations are called diagnostic centers, free standing facilities or ambulatory surgery centers, depending on the type of test or procedure you need. Unlike hospital settings, these locations may not have a copay or out of pocket expense, depending on your benefit plan.

When you visit your provider and he/she orders a test or procedure make sure to discuss with them your options of location as that may have a financial impact on you.

Last Updated: 
October 1, 2018