Referrals and Authorizations

Authorization is the approval you need from us for certain services to be covered.

There are different types of authorizations:

  • Preauthorization is done before you receive medical services. It can take up to two weeks to process for Utah members, two business days for Idaho members, ten business days for Nevada members, and five business days for Colorado members, though exceptions may apply for emergency care.
  • A concurrent authorization or concurrent review is done while you are receiving care, for example, if you are already in the hospital. If you request more services—in addition to those already approved—we'll work with your doctor and the facility staff to make sure that care is received in an appropriate setting. We will help the facility caregivers plan for your transition home or to another care setting.
  • A post-service authorization is obtained after a service has been provided. An example is emergency care, when it is not safe or reasonable to wait for authorization before obtaining treatment.

Preauthorization requirements can vary. In some instances, it is your responsibility to preauthorize, and in others it is your provider’s. To learn more about this, and to see which services require preauthorization on your plan, see your member materials or call Member Services at 800-538-5038. We are available weekdays, from 7:00 am to 8:00 pm, and Saturdays, from 9:00 a.m. to 2:00 p.m. TTY users, please call 711. Member Services can also help if you’d like to request a preauthorization.

Services* that often require preauthorization may include:

  • All admissions to facilities, including rehabilitation, transitional care, skilled nursing, and all hospitalizations that are not for Urgent or Emergency Conditions
  • All nonroutine obstetrics admissions, maternity stays longer than two days for a normal delivery or longer than four days for a cesarean section, and deliveries outside of the Service Area
  • Automated home blood pressure monitoring equipment (neonatal/pediatric)
  • All Services obtained outside of the United States unless for Routine Care, an Urgent Condition, or an Emergency Condition
  • Certain advanced imaging including Magnetic Resonance Imaging (MRI), Computerized Tomography (CT) scans, Positron Emission Tomography (PET) scans, and cardiac imaging
  • Certain genetic testing
  • Certain Home Healthcare
  • Certain medical oncology drugs
  • Certain radiation therapies
  • Certain sleep studies
  • Certain ultrasounds
  • Certain vein procedures
  • Cochlear implants, and osseointegrated auditory devices
  • Continuous glucose monitors
  • Dental anesthesia
  • Hospital level care at home
  • Hospice Care, Private Duty Nursing
  • Hysterectomy
  • Insulin pumps
  • Joint replacement
  • Organ transplants
  • Pain management/pain clinic Services
  • Surgeries on vertebral bodies, vertebral joints, spinal discs
  • The following Durable Medical Equipment:
    • i. Continuous Positive Airway Pressure (CPAP) and Bilevel Positive Airway Pressure (BiPAP)
    • ii. Prosthetics (except eye prosthetics)
    • iii. Negative pressure wound therapy electrical pump (wound vac)
    • iv. Motorized or customized wheelchairs
    • v. DME with a purchase price over $5,000
  • The following Mental Health/Chemical Dependency Services that are not for Emergency Conditions:
    • i. Inpatient psychiatric/detoxification admissions
    • ii. Residential treatment after the third day of admission
    • iii. Day treatment
    • iv. Partial hospitalization after 20 visits
    • v. Intensive outpatient treatment after 35 visits 
  • The medications listed on You may also request this list by calling Pharmacy Services at 800-538-5038.
  • Tonsillectomy

*This list of services is not all-inclusive.

If you fail to preauthorize these services, your benefits may be denied or reduced.