Prior Authorization

90.2 – Prior Authorization (Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) PFFS plans can perform retrospective review of claims for the purpose of verifying medical necessity and that the service furnished is a covered service. However, PFFS plans may not require members or providers to obtain prior authorization from the plan as a condition of coverage. Prior authorization occurs when a plan requires its members or their providers to seek approval from the plan before the member receives a service from the provider as a condition of coverage. However, as described below both enrollees and providers are entitled to request and receive an advance determination of coverage if they want to ensure that a particular service will be covered by the PFFS plan as described below under section 100.