Prior Authorization

Prior authorization is the process of obtaining written approval from Aspirus Health Plan for services or products before they are received. The prior authorization form is a document submitted to Aspirus Health Plan by your medical care provider. In reviewing a prior authorization request, proposed services are subject to all plan provisions, including medical necessity requirements and plan exclusions, among others.

Be sure prior authorization requests are approved before obtaining care. It is ultimately the member’s responsibility to make sure prior authorization forms are submitted and approved by Aspirus Health Plan prior to receiving care.

Authorization Forms and Lists

• Clinical Trial Notification Form (PDF)
• Continuity of Care Form (PDF)
• Medical Drug Prior Authorization List (PDF)
• Medical Services Prior Authorization List (PDF)
• Out-of-Network Referral Request Form (PDF)
• Peer to Peer Discussion Request Form (PDF)
• Pharmacy Drug Prior Authorization List (PDF)
• Pharmacy Exception to Coverage Request Form (PDF)
• Prior Authorization Request Form (PDF)

For more information or questions

If you have questions about prior authorizations, please call the number located on your ID card or contact Member Services at 866.631.5404.

Before requesting a prior authorization

Aspirus Health Plan encourages that you review your health plan for specific authorization requirements, excluded services/treatments, and referral requirements.

Non-participating providers

If your prior authorization is approved, the non-participating provider reimbursement value will apply to out-of-network providers and services. The amount the plan pays is the allowed amount for any covered service. But if an out-of-network provider charges more than the allowed amount, you may have to pay the difference.

Here’s an example: You go to an out-of-network hospital, which charges $1,500 for an overnight stay. If the allowed amount is $1,000, you may have to pay the $500 difference.

Prior authorization is required for some inpatient admissions

Different standards apply depending on whether the admission is acute or elective.

• Acute admissions: Members (or the facility) must notify Aspirus Health Plan within two days of an acute (direct or emergency) admission. Notification may be provided in writing or by telephone using the phone number located on your ID card or by calling 866.631.5404.
• Elective admissions: Providers must submit a prior authorization request a minimum of three days prior to an elective (non-emergency) hospital admission or admission to a residential treatment program for treatment of alcoholism, drug abuse, or nervous or mental disorders.