Members

Prior Authorization

Prior Authorization- means the written approval by WINhealth Partners of a service or procedure based on a request from a Participating Provider prior to the service or procedure being rendered when applicable criteria for the service or procedure has been met. Preauthorization is based on Medical Necessity and is not a guarantee of benefits and is subject to the plan provisions in effect at the time of service. In an emergency situation, an authorization should be requested within forty-eight (48) hours of the services being rendered. The member should contact WINhealth Partners to determine benefit coverage and preauthorization requirements. The requesting or referring provider must initiate the Preauthorization process. The Member should ensure that Preauthorization has been obtained from WINhealth Partners prior to obtaining services by contacting Member Services. WINhealth Partners will determine whether the requested service can be Preauthorized and will provide written notification to the Member and the provider verifying the authorization or notifying the provider of the inability to provide Preauthorization.

The following services require preauthorization to be covered, whether rendered in or out of network. When a member is being treated by a non-contract provider and neither the member nor the provider has obtained pre-authorization from WINhealth Partners, the services being rendered will be subject to plan rules that could result in the denial of payment.

Click here to see a list of services requiring prior authorization. This list is not all inclusive and is subject to change.