Services Requiring Prior Authorization
Prior authorization is required before you receive certain covered services or supplies. In general, network providers are responsible for receiving prior authorization from Quantum or UHC before they provide these services to you. However, you are responsible for notifying Quantum or UHC for certain network benefits.
Below is a list of situations requiring authorization. You must receive prior authorization from Quantum Health or UHC in the following situations by calling the number on the back of your ID card.
- Elective admissions—five business days before admission
- Maternity (inpatient stays greater than 48 hours for regular delivery and 96 hours for Cesarean delivery)
- Skilled nursing/inpatient rehabilitation facilities
- Reconstructive procedures
- Nonelective admissions—within one business day or the same day of admission
- Durable medical equipment costing $1,000 or more
- Home health care
- Hospice care
- Inpatient services for mental health or substance use disorder conditions
- Transplants
- Congenital heart disease—as soon as it is suspected or diagnosed (in utero detection, at birth, or as determined and before the time an evaluation for CHD is performed)
- Sleep studies
- ABA Therapy for Autism
If you do not follow the plan’s requirement for authorization as explained in the Benefits Handbook under “Your Responsibility for Prior Authorization” and/or you use non-network providers, you may be subject to a penalty.
Prior authorization is not a guarantee or a determination of benefits.