Prior Authorization

How It Works

Work with your provider. They know which services need to be approved and can make the request. Both BCCHP and your doctor will agree what treatments are medically necessary. “Medically necessary” refers to getting care that:

• Protects life
• Keeps you from getting seriously ill or disabled
• Finds out what’s wrong or treats a disease, illness, or injury
• Helps you do things like eating, dressing, and bathing

BCCHP won’t pay for service from a provider that isn’t part of the BCCHP network if you don’t have approval. You can work with an out-of-network provider to receive approval before you get care.

Some services that do not need approval are:

• Primary care
• In-network specialist
• Family planning
• WHCP services (you must choose doctors in the network)
• Emergency care

Need to locate a provider? Search the Provider Finder^®.

How Does BCCHP Approve a Request?

Your doctors will use other tools to check prior authorization needs. Tools used by PCPs (or specialists) include medical codes. Our doctors and staff make decisions about your care based on need and benefits. They use what is called clinical criteria. This helps to make sure you get the health care you need. Medical policies are also used to guide care decisions. Medical policies are based on scientific and medical research.

Coverage Decisions

BCCHP has strict rules about how decisions are made about your care. Our doctors and staff make decisions about your care based only on need and benefits. There are no rewards to deny or promote care. BCCHP does not encourage doctors to give less care than you need. Doctors are not paid to deny care.

You can talk to a BCCHP staff member about our utilization management (UM) process. UM means we look at medical records, claims, and prior authorization requests. This is to make sure services are medically necessary. We also check that services are provided in the right setting. We also look to make sure the treatment is consistent with the condition reported. If you want to know more about this process or how decisions are made about your care, contact us. Call Member Services at 1-877-860-2837 (TTY/TDD: 711).