Prior Authorization/Referral
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.
Below is a list of services that require prior authorization from ‘Ohana Health Plan before your healthcare provider can proceed with treatment.
Prior Authorization List
SERVICES THAT REQUIRE A PRIOR AUTHORIZATION | PRIOR AUTHORIZATION REQUIRED FOR SOME OR ALL OF THE SERVICES? |
|---|---|
Ambulatory Surgery Center | Some services require prior authorization |
Bariatric Surgery (certain restrictions and limitations may apply) | Yes |
Birthing Centers | Yes |
Durable Medical Equipment | Some items require prior authorization |
High-Cost Radiology | Yes |
Home Health Care Services | Yes |
Hospice Care | Yes |
Hospital Services Inpatient | Yes |
Hospital Services Outpatient | Some services require prior authorization |
Laboratory Services: All services necessary for the diagnosis, treatment and prevention of disease, and for the maintenance of health. | Some services require prior authorization |
Maternity Services | Some services require prior authorization |
Medical Services Clinic | Yes |
Orthotics & Prosthetics (O&P): Braces (non-dental) and other mechanical or molded devices to support or correct any defect of form or function of the human body. | Yes |
Oxygen & Respiratory Services | Some services require prior authorization |
Pain Management | Some services require prior authorization |
Substance Use Disorder Services | Some services require prior authorization |
Therapy (OT, PT, ST) Services (outpatient) | Yes |
Transplant Services | Some services require prior authorization; Some services are covered under the State of Hawai‘i Organ and Tissue Transplant Program, not the QUEST Integration program. |
All such services determined by Hawaii Medicaid to be medically necessary shall constitute an Ohana Health Plan Covered Service. See the Ohana Health Plan Member Handbook for more information on coverage out-of-network and out of the Ohana Health Plan service area.
*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.