Prior Authorization is:
It is the process by which GHC-SCW gives prior written approval for coverage of specified services, treatment, durable medical equipment (DME) and supplies. Prior Authorization will determine and authorize payment of:
- The specific type and extent of care, DME, or supply that is medically necessary.
- The number of visits or the period of time during which the care will be provided.
- The name of the provider rendering the service.
Prior Authorization is not:
- A guarantee the service or supply will be covered. Coverage is determined by the member’s benefit plan and is subject to Usual and Customary Reimbursement (UCR) determinations.
- Unlimited – Prior Authorization approvals may be limited by visits and/or time span.
GHC-SCW requires prior authorization for all services and supplies as outlined within this website. This requirement applies whether GHC-SCW is considered the primary insurer, secondary insurer, or insurance is supplementary to Medicare.
Notifications can be made via telephone to:
- GHC-SCW Care Management Department Toll Free: (800) 605-4327 ext. 4514 Local: (608) 257-5294
- GHC-SCW Behavioral Health Department Local: (608) 441-3290
Participating providers should log into EpicLink to submit a request for prior authorization and to verify that GHC-SCW has approved the request. Requests should be submitted at least two weeks prior to scheduled date of service whenever possible.
If you do not have access to authorizations through EpicLink, you may contact your Provider Coordinator to assist in getting your access updated.
HMO Members: If a participating provider does not obtain prior authorization and the requested service or supply is denied, a member cannot be billed.
- Members using non-participating providers are responsible for working with the provider to obtain all necessary prior authorizations.
- If an HMO member is using an Out-of-Network (OON) provider, and does not obtain prior authorization, and the requested service or supply is denied, the member will be billed.
- HMO Members: If a participating provider does not obtain prior authorization and the requested service or supply is denied, a member cannot be billed.
- Members should log into MyChart prior to their visit to verify that GHC-SCW has approved the request for prior authorization. If you don’t have access to MyChart, you can request an account online or contact Member Services at (800) 605-4327 or (608) 828-4853.
Services That Require Prior Authorization
How to Submit Prior Authorization Request
|Autism Spectrum Disorder Services||
|Durable Medical Equipment||Must Meet Medical Necessity|
|GHC Foundations IOP||
|Home Care Services||
|Mental Health/Behavioral Health Services||
Are you a Behavioral Health provider who has been asked to submit additional documentation?
|Out of Network Provider Services for HMO Members|
|Outpatient Surgery |
|Pharmacy and Other Medication Requests||
|Physical Therapy, Occupational Therapy, Speech Therapy or Vision Therapy
||Prior Authorization is not required when provided by a GHC-SCW physical or occupational therapist.|
|Specialty Injectable Medications||
|Substance Use Disorder Services||
Services Not Covered:
- Cosmetic Surgery
- Experimental and/or Investigational Services
- Medication Related Questions & Requests: Contact the
GHC-SCW Pharmacy department at (608) 828-4811.
- Coverage and Prior Authorization Requirements: Contact Member Services, Mon. – Fri., 8 a.m. – 5 p.m. at (608) 828-4853 or toll free at 800-605-4327, and ask to speak with Member Services.
- Prior Authorization Status: Check your status through GHC EpicLink or contact GHC-SCW Care Management team by phone (608) 257-5294, or by fax (608) 831-6099.