Prior Authorization

Commercial, BadgerCare Plus and Medicaid SSI plans.


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.

  • 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.

    2023 Prior Authorization Guidelines 
    Provider Forms and Resources