Welcome back! In our previous post, "What is Pre-Authorization and When is it Required?", we defined pre-authorization as your clinical "green light" and detailed the complex services that require it. Now, we shift focus from the what to the why. The pre-authorization protocol is a fundamental function designed to secure both your clinical well-being and your financial stability.
Let's take a deeper look at the significant protections the pre-authorization protocol provides:
1. Ensuring medically appropriate care: Our dedicated team of experienced registered nurses, physicians, and clinicians review every (yes, every!) request through evidence-based clinical guidelines. We ensure the proposed service is the most appropriate, effective, and safe intervention for your diagnosis covered by your health plan.
2. Preventing surprise bills and financial trauma: This is perhaps the most significant member benefit. Obtaining pre-authorization in advance is a formal commitment from your health plan to cover that specific service.
Minimizes the risk of a retrospective denial, which is what leads to those unexpected and costly out-of-pocket bills.
By confirming coverage before the service is rendered, we empower you to confidently proceed with care, effectively preventing avoidable financial exposure.
3. Supporting sustainable, cost-effective care: From a stewardship perspective, pre-authorization is a vital tool for managing escalating healthcare costs for the benefit of all plan participants. It encourages the selection of clinically proven, yet cost-effective, options when appropriate, helping to maintain long-term plan affordability.
Securing a smooth process
While your healthcare provider's office is primarily responsible for submitting the request and necessary clinical documentation, your informed involvement is crucial for a smooth and timely experience.
3-step action plan to a smooth process:
Ask early: When your physician recommends a major procedure or high-cost test, ask them directly: "Does this require pre-authorization from my health plan?"
Verify your ID: Always furnish your most current member ID card to their administrative staff to ensure they use the correct contact and plan details.
Confirm submission: A few days after the service is recommended, confidently follow up with your provider's office to confirm the request has been successfully submitted to First Choice Health Medical Management.
Next steps: Access your benefits
Pre-authorization is not frivolous paperwork; it is a fundamental, patient-centered step that actively protects both your clinical health and your financial future.
To ensure seamless care and financial protection, please take these actions today:
Review your plan: Log into the First Choice Health Member Portal to download your specific plan documents and review the full list of services that require prior authorization.
Call us: If you or your provider have any questions regarding medical necessity or benefit coverage, instruct them to call the First Choice Health Medical Management team directly using the number on the back of your member ID card.
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About Dave Agler, MD, MBA
Dr. Agler is the Chief Medical Officer for First Choice Health and provides leadership to the Medical Management department. He is a graduate of the University of Southern California Keck School of Medicine and has also earned an MBA from Boise State University. He completed his Family Medicine Residency at Group Health Cooperative in Seattle and is Board Certified in Family Medicine. He practiced as a Family Medicine physician for over a decade in myriad healthcare settings before moving into the health payor space. Prior to joining the FCH team, Dr. Agler was the State Medical Director for Idaho Medicaid and the Regional Medical Director at Humana.