Prior authorization (also known as pre-determination) may be required for certain prescription drugs, therapeutic equipment, home nursing, and Major or Orthodontic dental expenses, as detailed in your Booklets. Generally, expenses over $500 should be submitted to GroupSource for pre-authorization prior to purchase or rental. Note: If pre-authorization is not obtained, the Insurer will only reimburse the claim on the basis of the recommendations that would have been made if the pre-authorization had been submitted (i.e. a portion of the claim may be denied).
- To request pre-authorization, submit all required documentation with an Extended Health Care Claim Form with “Pre-authorization” written along the top. Dental office will usually submit a pre-determination electronically on your behalf.
- Provide additional documentation required by GroupSource, such as a letter from the physician outlining the medical condition and confirming the item(s) necessary for treatment, together with quotes for purchase or rental. For advice on what information is needed please contact our claims department before submitting your pre-determination.
- Appeals of previously-denied estimates may be resubmitted with extra details (i.e. supporting x-rays and/or physician/dentist statements, as requested by GroupSource).
- Advise members that once they receive the pre-authorization, they should have the work completed, or the product purchased, as soon as possible. If there are changes to your plan between the time the member receives the pre-authorization and the date of service, the claim may be rejected or adjusted to reflect the changes made to your plan.