Prior Authorization

For some types of care, your primary care provider (PCP) or specialist will need to ask HPSM for permission before you get the care. This is called asking for prior authorization, prior approval or pre-approval. It means that HPSM must make sure that the care is medically necessary or needed.

Care is medically necessary if it is reasonable and necessary to protect your life, keeps you from becoming seriously ill or disabled, or alleviates severe pain. For emergency care, you never need prior authorization. Even out-of-network emergency care is covered. This includes having a baby.

The following always need prior authorization even if you get them from an HPSM network provider.

• Hospitalization, including long term care
  
• Services outside of the HPSM service area
  
• Outpatient surgery
  
• Long-term therapy
  
• Specialized care
  
• Specialized radiology procedures (such as a CT scan or an MRI)
  

How to check if you need prior authorization

• Ask your primary care provider (PCP).
  Your PCP's phone number is on your HPSM member ID card.
• Check HPSM's Prior Authorization Required List
  Note that a treatment can have multiple procedure codes. If you do not know the procedure code(s) or name(s) for the treatment you want, ask your provider.
  

Prior authorization is based on medical necessity and not a guarantee of coverage or eligibility. If a service requires prior authorization, "Yes" or "Conditional" will appear in the search results. However, that does not mean it is a covered benefit. To find out if a service is a covered benefit, call your provider or HPSM.

Use the search tool

This search tool includes all current CPT codes that require prior authorization. If the code you look up appears in the search results, you must ask your provider to complete and submit a Prior Authorizations Request Form. Wait for authorization approval from HPSM before getting the service. Codes are updated quarterly.