What is preauthorization?

If you are in need of certain procedures or prescriptions that are covered under your plan, they may require preauthorization. This means that your provider will submit a request to EMI Health to confirm whether the procedure or prescription is medically necessary. Read below for more information on the preauthorization process. 

Preauthorization is not a guarantee of coverage. Before beginning the preauthorization process, please call our customer service team at 801-262-7475 or toll free at 800-662-5851 to confirm whether the procedure or medication is covered under your plan.  

When do I need preauthorization?

In general, more specialized procedures and medications require preauthorization. See below for a list of common treatments that require it. For more detailed information on preauthorization requirements, contact our customer service team. 

• Hospitalizations and inpatient facility admissions
• Surgeries in a hospital or ambulatory surgical facility
• Major diagnostic tests
• Home health services

How do I initiate preauthorization?

Speak with your provider as they must initiate the preauthorization request and submit the necessary documentation.

What happens now?

Once your provider submits your preauthorization request with all the necessary information, EMI Health will begin the review process. This process typically takes between 5-7 business days, but it can take up to 15 days. Urgent requests will be reviewed within 72 hours after EMI Health has received them.

What happens if it's denied?

If your preauthorization is denied, both you and your provider will receive a denial letter in the mail with the specific denial rationale. Sometimes, preauthorization is denied because providers haven't submitted all necessary information. If you'd like to appeal, contact your provider to initiate the process. 

You are entitled to two appeals. The first appeal must be received by EMI Health within 180 days of the denial. The second appeal must be received by EMI Health within 60 days of the denial of your first appeal.

Retrospective Authorizations

In some cases, retro authorizations are applicable. This means that if you received a procedure or medication that required preauthorization but your provider didn't seek preauthorization prior to the date of service, you may be able to get authorization after the fact.

You can submit a request up to one year after the date of the procedure. Please ask your provider to initiate the retro review request and submit the necessary supporting documentation. 

Important Note

Please remember that preauthorization is not a guarantee of coverage. To confirm whether the procedure is covered under your benefits, contact our customer service team at 801-262-7475 or toll free at 800-662-5851.