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Prior Authorization

Prior Authorization

Prior authorization is the process of obtaining written approval from Aspirus Arise for services or products before they are received. The prior authorization form is a document submitted to Aspirus Arise 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 Arise prior to receiving care.

For covered products and services provided by non-participating providers, Aspirus Arise will pay up to the Maximum Out-of-Network Allowable Fee. You are responsible for any charge that exceeds the Maximum Out-of-Network Allowable Fee for covered services received from non-participating providers.

For more information or questions

Please call the phone number located on the member ID card. If the ID card is unavailable, please contact Member Services at 800-332-3297. Providers can also reference the Aspirus Arise Provider Manual for more details.

Tips and Tricks

Before requesting a prior authorization:

  • Providers should verify member eligibility and benefits through the Provider Portal.
  • Members should review their health plan for specific authorization requirements, excluded services/treatments, and referral requirements.

Prior authorization is required for some inpatient admissions.

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

  • 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.
  • Acute admissions: Members (or the facility) must notify Aspirus Arise within two days of an acute (direct or emergency) admission. Notification may be provided in writing or by calling the phone number located on the member ID card or by calling Member Services at 800-332-3297.

Providers should submit clinical information to support the admission through iExchange.

Inpatient admissions include a member’s admission to:

  • Inpatient hospital
  • Hospice inpatient facility
  • Inpatient rehabilitation facility
  • Skilled nursing facility, when Medicare is not primary
  • Inpatient and residential facility for Behavioral Health Services

Prior authorization is required for all non-emergency ambulance transfers between facilities. Prior authorization is required for any service, procedure, or equipment. The Prior Authorization List of Services is reviewed and updated regularly.

  • Clinical information should be attached to the prior authorization request form or iExchange request.
  • A mailing address and fax number are available on the prior authorization request form. Clinical documentation should be attached to the request form.
  • Non-Covered Services and Procedures List is reviewed and updated regularly.
  • Services that are exclusions of the member’s health plan or listed on the Non-Covered Services and Procedures Policy are not typically prior authorized.

Pharmacy prior authorization requests should be submitted following the instructions on the Drug Prior Authorization List.

  • To determine if a service needs an Outpatient Behavioral Health Review, please call Member Services at 800-332-3297.
  • Prior authorization requests for remaining services should be submitted with clinical information via iExchange.
    • Need to register for an iExchange account or have questions? Please visit the iExchange Resource page, or email us at iexchange@wpsic.com.

Radiology Authorization

Aspirus Arise collaborates with National Imaging Associates, Inc. (NIA), a subsidiary of Magellan Health Services, for evidence-based management of outpatient radiology benefits. NIA offers a unique combination of superior clinical expertise in radiology, operational excellence, and financial strength and stability.

With NIA, you can access the Utilization Review Matrix, quick start guide, imaging authorization, resources, and more. Whether you are submitting imaging exam requests or checking the status of ordered exams, you will discover that NIA is an efficient, easy-to-use resource.

Create an account today!

Low Back Surgery Authorization

Prior authorization is required for coverage of a low back surgery. Before a participating Orthopedic Surgeon or Neurosurgeon performs a low back surgery, an optimal regimen of Conservative Care, as determined by Aspirus Arise, must be completed. Prior authorization must be obtained prior to services being rendered.

 

Conservative Care provided or directed by a provider who is not an Orthopedic Surgeon or Neurosurgeon must consist of ALL of the following:

  • Chronic low back pain with symptoms present for at least three months; AND
  • Medical records include documentation of what functional disability is caused by the pain; AND
  • Pain is moderate to severe in nature; AND
  • Medical records include documentation of pain severity. (Oswestry Score, Pain Visual Analog Scale, or other validated measure); AND
  • Failure of at least six weeks of conservative measures with two or more modalities including: prescription pharmaceuticals, such as non-steroidal anti-inflammatory agents, anticonvulsants and antidepressants; physical and restorative therapies, including spinal manipulation, physical therapy with a home exercise program and advice to stay active; chiropractic management with a home exercise program and advice to stay active, and injection therapy (epidural steroid injection, intraarticular facet joint injection, and radio frequency ablation).

If the symptoms require urgent medical care due to severity, the trial of conservative therapy may be waived by the treating provider.

Drug Prior Authorization Program

The Aspirus Arise drug prior authorization program supports evidence-based treatment and is intended to optimize the care provided by providers to our members. Drugs subject to prior authorization may have specific safety issues, may require a higher level of care coordination, and may compete with other products that offer similar or greater value, or may require specific testing to identify appropriate patients. The prior authorization process gathers information so that a coverage decision can be rendered.

Specialty Drugs
Aspirus Arise has engaged with Diplomat to assist with specialty drug management. Diplomat will review each treatment plan relative to evidence-based guidelines that may include step-therapy protocols. Diplomat will ensure the specialty drug is provided in the most appropriate, cost-effective setting. This includes self-administration or the home setting depending on the situation.

Specialty drugs dispensed without proper authorization will not be reimbursed and the member will not be billed for the balance. A provider can initiate a specialty drug authorization by calling Diplomat at 888-515-1357. To view coverage policies for specialty drugs, click here.

Non-specialty Drugs
Non-specialty drugs that require review are reviewed by our Pharmacy Benefit Manager, or in rare instances, Aspirus Arise.

Kidney Dialysis Prior Authorization Request Form

Kidney Dialysis Prior Authorization Request Form