Before beginning the preauthorization process, please confirm whether the procedure requires preauthorization and whether it is covered under your patient's plan. Preauthorization is not a guarantee of coverage.
You can find a more detailed list of procedures and medications that require preauthorization here. If you know the procedure code, search here. You can also contact our customer service team at 801-262-7475 or toll free at 800-662-5851 as they will have more information on preauthorization requirements.
To receive preauthorization, you must submit a review for medical necessity. Once medical necessity is determined and EMI Health finalizes the authorization, we will send a letter with an authorization number to you and your patient outlining the information.
Click here for more information on where to send the necessary information for medical necessity.
The review process begins once we receive the required supporting documentation. 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.
Please note: If the request is initiated but no supporting documentation is received, the process will be delayed and possibly denied for Lack of Information.
Oftentimes, preauthorization is denied because we haven't received all the necessary information. When submitting your request, please ensure that you are providing all supporting documentation. For example, submitting test results alone will likely result in denial. You should also submit notes, patient history, and anything else that helps us understand the patient's medical history and need for the requested treatment.
Patients are entitled to two appeals. The first appeal must be received by EMI Health within 180 days of denial. The second appeal must be received by EMI Health within 60 days of the denial of the first appeal.
Appeals should include a letter stating intent to appeal. Please do not simply send notes, as we will not know what your intent is. If specific information is missing or if specific criteria are listed in the denial letter, be sure to include this information in your appeal.
In some cases, retro authorizations are applicable. You can submit a request up to one year after the date of the procedure. Please be sure to include all relevant claim numbers and all supporting documentation for review. If the request is for a drug, be sure to include the drug name, dosage, frequency, and treatment span.
For more detailed information on preauthorization requirements and how to submit the necessary information, click here.
Please remember that preauthorization is not a guarantee of coverage. If you have any questions, you can always contact our customer service team at 801-262-7475 or toll free at 800-662-5851.