Prior authorization is a process to review certain treatments, services or procedures. It’s required before you can get certain tests, treatments, medication or supplies. We require prior authorization so we can make sure you’re getting the care you need. Services obtained by an out-of-plan provider/facility require prior authorization.
Referrals and prior authorizations
You want to get the care you need when you need it. We make it easy.
Referrals
HMO members: Need to see a specialist? No problem. With HAP, specialty office visits don't require referrals from your primary care physician (PCP). But in some cases, the specialist you see may require a referral from your PCP. Many specialists are booked out months in advance, and may only accept patients whose PCP believes they need specialty care.
PPO members: You don't need to worry about referrals, but your PCP would be a good resource to find a specialist who is right for you. With a PPO plan, you have the flexibility to seek care from doctors in and out of the network. But remember, you might pay more if you choose a doctor outside of our network.
Prior authorization
Before you go to the doctor or have services performed, it's important to understand our approval process. There are common treatments and procedures that require approval before you get them. This is also known as prior authorization.
If your service requires prior authorization, your doctor will take care of it on your behalf.
Example:
When Mary visits the ear, nose and throat (ENT) doctor for the first time, she pays her specialist office copay. After her consultation, the ENT recommends a sinus surgery for Mary. Before she has the surgery, the ENT's office will need to verify if the surgery is covered and if a prior authorization is needed from HAP.
For hospital stays
For inpatient hospital stays, your doctor will get prior authorization from HAP. Emergency room visits don't require prior authorization. The hospital will notify HAP within 48 hours of the emergency admission.
Prior authorization FAQs
Your doctor submits a request based on the recommended treatment. Then, you and your doctor will receive a notice of approval or denial within 7 days*. Your request must be approved before you accept treatment or services. If you’re not approved, you may be responsible for the entire cost of your care.
*ASO and FEHB members will receive a notice of approval within 14 days.
Based on your plan type, you can review prescription medications that require prior authorization at: hap.org/prescription-drug.
You can view a summary of the services/procedures that require prior authorization from HAP either at: hap.org/clinical-criteria.
OR
Log in at hap.org and select MyCare and then Referrals and Prior Authorizations.
If your request is denied, you have the right to know why. Requests can be denied for various reasons. If the service is denied, you will receive a letter that includes the rationale for the denial, along with appeal information. If you need more information, talk to your doctor or call the number on your ID card.
If you have questions about the prior authorization request process or your benefits and coverage, please contact Customer Service.
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