Prior Authorization
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Prior authorization performs the following functions:

  • Confirms that the service is medically necessary and appropriate
  • Confirms that the member is effective at the time of the requests and service dates
  • Assists healthcare professionals in providing appropriate, timely, and cost-effective services.
  • Directs members to the appropriate level of care and place of service.
  • Determines eligibility of requested service in advance i.e. that the service is a covered benefit.
  • Identifies opportunities for case/disease management
  • Ensures delivering of care in the most appropriate and cost effective setting

MAHP requires prior authorization on such services as out of plan referrals, PET scans, same day surgeries, elective admissions, etc. Failure to obtain prior authorization will result in denial of coverage.

If you have any questions regarding prior authorization, please contact Health Care Services at 563-584-4885 or 1-866-821-1365.

Durable Medical Equipment

  • Durable Medical Equipment (DME) requires prior authorization by MAHP if it is over $500 in most of our contracts.
  • To ensure proper utilization of DME, please keep in mind the following:
  • Physician ordering the DME should be the physician who is actually treating the patient for the condition,
  • The medical record must contain adequate documentation to support the need for the equipment,
  • The Certificate of Medical Necessity (CMN) should be read and verified it is correct prior to physician signing off on it,
  • Prior authorization needs to be obtained prior to the receipt of the Equipment,
  • Member needs to be instructed to return all rental items or make arrangement to return the item with the DME provider when it is no longer being utilized, and
  • Many of our members have a 20% co-insurance on DME items so it is in the best interest of all that MAHP is authorizing only DME that is medically indicated.

Medical Technology
Medical Associates Health Plans has an established policy and procedure to formalize the process by which the Plan evaluates the inclusion of new medical technologies and the new application of existing technologies, including medical procedures, pharmaceutical, behavioral health procedures, and devices into the benefit package. Before a new technology is approved for coverage, there is a review process that it must go through. The new technology must meet the following criteria:

  1. The technology must have final approval from the appropriate government regulatory bodies.
  2. The scientific evidence must permit conclusions concerning the effect of the technology in health outcomes.
  3. The technology must improve the net health outcome.
  4. The technology must be as beneficial as any established alternatives.
  5. The improvement must be attainable outside the investigational setting.

All requests for new technology are reviewed by Utilization Management Committee, Quality improvement Committee, and with the Medical Associates Clinic Board of Directors giving the final approval.