Pre-Service Authorizations

The Alliance UM Department must review and approve select services before they are provided. Clinical review determines whether the service is clinically appropriate, performed in the appropriate setting, and a part of our covered benefits.

Clinical information is necessary for all services that require a medical necessity review. The requesting provider must select the “Type of Request” on the Prior Authorization (PA) Request Form. Providers must also include all supporting clinical information with the initial request to help ensure a timely decision. If the clinical review information is not received with the PA Request Form, our UM team will contact the provider to collect the needed information.

Clinical information about a member may include:

  • Consultations
  • Diagnostic results
  • History of presenting problem
  • Member’s response to treatment
  • Photographs
  • Physical assessment
  • Previous and current treatment

Clinical information should be provided at least five (5) days prior to the planned service date to ensure timely notification of coverage approval. The provider is responsible for obtaining authorization. Please provide an authorization reference number on all referrals and claims.

Prior Authorization Request – Determination Turnaround Times
Non-Urgent Requests Within five (5) business days of receipt.
Urgent Requests Within 72 hours of receipt.
Urgent Concurrent Decisions Within 24 hours of notification, if clinical is available; 72 hours if clinical is requested.
Post-Service Decisions Considered if submitted within 30 days of date of service.

Post-Service/Retrospective Review

Post-Service/retrospective review is the process in which utilization review is used to determine medical necessity or coverage under the health plan benefit. Post-service/retrospective authorizations only considered if submitted within 30 days of the date of service.