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Prior Authorization

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Prior Authorization
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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.
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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.
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Providers Responsibilities

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.

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Members Responsibilities

  • 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.
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Services That Require Prior Authorization

Review this list of services that require prior authorization. Submit request via EpicLink if you have EpicLink access already. If you don't have access to EpicLink, please submit requests via online prior authorization forms below. Failure to obtain Prior Authorization may result in GHC-SCW not providing coverage for the service. The prior authorization lists may differ depending on health plan type.

Service

Details

How to Submit Prior Authorization Request

Advanced Imaging
  • CT/CTA
  • MRI/MRA
  • SPECT
  • PET
Autism Spectrum Disorder Services
  • Diagnostic Evaluation
  • Outpatient Services
Cardiopulmonary Rehab  
Durable Medical Equipment (DME) GHC-SCW offers a variety of durable medical equipment (DME) options from our own clinics, UW Health Care Direct, Edgepark and many other local and national vendors.

Members will generally need a prior authorization for DME.

Coverage includes:

  • CPAPs
  • Breast pumps
  • Crutches
  • Orthotics
  • Hearing Aids
  • Wheelchairs
  • And Many Other Items

Please contact GHC-SCW Member Services at (608) 828-4853 or (800) 605-4327 to discuss the best way to access your DME needs.

Genetic Testing  
GHC Foundations IOP
Home Care Services
  • Home Health
  • Home Infusion

 

Hospice  
Inpatient Admissions
  • Hospitals, acute inpatient care
  • Inpatient Rehab Facilities
  • Long Term Acute Care (LTAC)
  • Psychiatric Admissions
  • Residential Treatment Behavioral Health
  • Skilled Nursing Facility/swing bed

 

Mental Health/Behavioral Health Services
  • Neuropsychological Testing
  • Psychological Testing
  • Intensive Outpatient Program (IOP)
  • Partial Hospitalization Program (PHP)
  • Day Treatment Program
  • Electroconvulsive Therapy (ECT)
  • Transcranial Magnetic Stimulation (TMS)

Are you a Behavioral Health provider who has been asked to submit additional documentation?

Orthodontic Care  
Out of Network Provider Services for HMO Members  
Outpatient Surgery ​  
Perinatology  
Pharmacy and Other Medication Requests  

  • Medications listed on Formulary as “PA” (prior authorization) and those not listed on Formulary require submission of additional health information for consideration of coverage.

 

 

  • Complete a prior authorization request form by visiting Navitus.  Select “Prescribers” and login using your NPI number and state of practice.
  • When a drug-specific prior authorization form is not listed, the M​edication Prior Authorization Request form may be used. The completed form should be faxed to the GHC-SCW number on the form.
  • Oncology Drugs (Including Those Requested For Non-Oncology Use) Are Managed By Our Partner MagellanRx: Complete an electronic prior authorization request by visiting ih.magellanrx.com. The first time you access the site, you will use the link titled “New Access Request – Provider” and follow the prompts. Once access is granted, the prescriber may search for the requested medication and answer the associated questions. An oncology medication NOT found on this portal should be submitted in the same fashion as a non-oncology medication (see above).​​
  • Locating Medication Specific Forms: Visit Navitus, Select “Prescribers” and log in using your NPI number and state of practice.
  • Specialty Injectable Medications: Instructions for Submitting a Specialty Injectable Medications Prior Authorization and Full List
Physical Therapy, Occupational Therapy, Speech Therapy or Vision Therapy
Prior Authorization is not required when provided by a GHC-SCW physical or occupational therapist.
Sleep Studies  
Specialty Injectable Medications

 

Substance Use Disorder Services
  • Residential Treatment Substance Use
  • Intensive Outpatient Program (IOP)
  • Partial Hospitalization Program (PHP)

 

Services Not Covered:

  • Cosmetic Surgery
  • Experimental and/or Investigational Services

Are you a provider who has previously submitted a prior authorization request and have been asked to submit additional documentation?

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Call To Action

Questions?

  • 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.