Prior Authorization

Prior Authorization 101

Prior authorization requires the member or member’s provider to make a formal request to National Programmatic Utilization Alliance (NPUA) prior to receiving or rendering the requested service. The request will be reviewed first to determine eligibility of coverage and benefit availability. Appropriate documentation to support the prior authorization request must be submitted. The information submitted will be reviewed in accordance with the clinical policy and a determination will be made. The provider and member will receive notice identifying the prior authorization determination. 

The clinical review of a prior authorization request will be conducted by an appropriately trained and qualified NPUA reviewer in accordance with the written clinical, and internal policies for performing utilization review. The application of criteria to an individual situation requires consideration of all factors relevant to the criteria, including age, co-morbid conditions, prior history and progress of treatment, and may include other social factors. 


Prior Authorization

Prior authorization (sometimes called preauthorization or pre-certification) is a pre-service utilization management review. Prior authorization is required for some members’ services before services are rendered to confirm medical necessity or appropriateness as defined by the member’s health benefit plan. A prior authorization is not a guarantee of benefits or payment. The terms of the member’s plan control the available benefits.  

If you do not get pre-approval via the prior authorization process for services on our prior authorization lists, the service may not be covered. 

Yes, members can view the policies on the website or contact their Plan for more information. 

In most cases, the provider is responsible for requesting prior authorization before performing a service, but in some instances members may request the prior authorization. Contact your Plan’s member services representative if you have questions on how to request an authorization. 

Prior authorization can be submitted to NPUA via fax, over the phone, and through the provider portal. 

It is recommended that prior authorization requests be submitted a minimum of 7 days before the desired start date of service.  

Once a prior authorization request is received and processed, the decision is communicated to the provider and member.  

NPUA will typically render their determination within two days of receipt of all required information.

For information on your right to appeal, please reference