Commercial, BadgerCare Plus and Medicaid SSI plans.
Below are Group Health Cooperative of Eau Clare's Prior Authorization Guidelines for all commercial, BadgerCare Plus and Medicaid SSI plans.
Please note the following:
Authorization for services DOES NOT guarantee payment for services. Payment for services is dependent on other non-medical criteria including benefits associated with a member’s specific plan and eligibility issues.
According to Federal Law (Section 1902(n)(3)(B) of the Social Security Act, as modified by section 4714 of the Balanced Budget Act of 1997), providers may not balance bill Medicaid members
If a member receives services that require an approved authorization by the Cooperative and such authorization is not obtained, or the authorization request was denied because services were not deemed medically necessary, all services (including out-of-network and future related services and/or follow-up care related to the services) will be denied. This includes any ancillary, facility, and/or professional charges.
Cooperative Advantage/D-SNP Providers: For all Medicare enrollees, hospitals must deliver valid, written notice of an enrollee's rights as a hospital inpatient, including discharge appeal rights, using the standardized form, CMS Form R-193, An Important Message from Medicare (IM). Furthermore, Hospitals and Critical Access Hospitals (CAHs) are required to provide written and verbal explanation to Original Medicare and Medicare Advantage enrollees who receive observation services as outpatients for more than 24 hours. Links to these documents can be found below:
FFS & MA IM | CMS - An Important Message from Medicare (IM)
FFS & MA MOON | CMS - Medicare Outpatient Observation Notice (MOON)
2024 Prior Authorization Guidelines
Express Scripts, Inc. Prior Authorization Resources
Provider Forms and Resources
UM Policies and Procedures