Guidelines for Prior Authorization

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.

• It is advised that authorization requests be submitted PRIOR to services being scheduled/performed. Typical turnaround of prior authorization requests is 3-5 business days, however it may take longer, depending on the situation. Services requiring approved authorization that are performed prior to obtaining approval are done at the risk of the provider not receiving payment.

  • 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.

• Group Health Cooperative of Eau Claire DOES NOT grant retro-authorization for services unless there is a compelling reason for consideration. At no time will a retroactive event authorization be approved for a time span greater than two weeks prior to the receipt date.

• 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.