PHC must approve some medical services, medical equipment, medical supplies and/or medications before you get them. Prior authorization means that both your doctor and PHC agree that the services you will get are medically necessary.
If you need something that requires prior authorization, the health care provider will send us a Treatment Authorization Request form (or "TAR" for short). Your provider knows which services require a TAR.
Non-emergency hospital care
Some types of medical supplies and durable medical equipment such as wheelchairs
Some outpatient diagnostic tests such as MRIs
When we get a TAR, it is reviewed by our medical staff (doctors, nurses and pharmacy staff). They review each case to make sure you are getting the best and most appropriate treatment for your medical condition.
We approve most TARs, but sometimes a TAR is deferred. This means that we need to ask the provider for more information or ask that he/she try another treatment first. We will let your doctor know if a TAR was approved, or if we need more information. Please check with your doctor if you want to know if a TAR has been approved or not. We respond to all TARs within five (5) business days from the time we receive them. If a treatment is urgent, we respond within one (1) business day.
After a TAR has been approved, the provider can give you the service or medication. In the few cases where a TAR is not approved, both you and the provider will get a letter from us within 1 business day. This is called a denial. The letter will tell you and the provider that the TAR was denied and why.
It will also tell you and the provider about your right to appeal the denial and gives you information on how to do that.
You can call our Member Services Department if you would like more information on how we make these decisions.