Services Requiring Prior Authorization
We need to approve some services before you can get them. This is called prior authorization or precertification.You may have to pay for these non-covered services if you do not receive a prior authorization from 'Ohana.
Your PCP or specialist will contact us to ask for this approval. If we do not approve them, we will notify you. We will give you information about the appeals process and your right to a DHS hearing if you disagree with our decision.
You need prior authorization for these services:
- Certain medical supplies and equipment
- Certain medical procedures done by your PCP or specialist
- Referrals to a case management agency and/or foster home placement
- Referrals or admission to a nursing home or residential home
- Surgical procedures
- Cosmetic procedures
- Non-emergency hospital services
- Any out-of-plan services or non-network care
- Home and community-based services
*list is not all inclusive
You can go to your Member Handbook or call Customer Service toll-free at 1-888-846-4262 (TTY 711) for the most up-to-date list.
We will make a decision within fourteen (14) days. We may need more time to make this decision. If so, we will then take up to fourteen (14) more calendar days. You or your doctor can ask us for a fast decision (a decision made within 72 hours after receipt of the request for service). You may ask for this if waiting for an approval could put your life or health in danger.
Sometimes we will need more time to make a fast decision. This can mean up to fourteen (14) more calendar days for us to make a decision or give approval.