Prior authorization
Security Health Plan wants our members to receive the right care at the right time and in the right place. By making sure our members don't receive tests and treatments that are unnecessary, prior authorization helps ensure high-quality care and helps control costs.
Prior authorization also ensures coverage and payment for certain services. Please have your doctor submit a prior authorization to Security Health Plan if you plan to receive any of these services.
If you need to see a specialist, such as a cardiologist, dermatologist or urologist for example, or use hospital services, you may see any provider listed in your plan's Provider Directory. Your primary care provider can help coordinate the visit and assist with a referral or prior authorization, if necessary.
When is prior authorization needed?
Prior authorization is required by Security Health Plan before receiving certain services to ensure coverage and payment for those services. Your provider will generally submit a prior authorization request on your behalf. We encourage you to ask questions to make sure the request has been submitted and approved. If your provider is not in the Security Health Plan network, you may need to contact Security Health Plan yourself to request prior authorization.
A healthcare provider may contact Security Health Plan to determine whether prior authorization is required for a member’s service or medical equipment by calling our Provider Assistance Line at (800) 548-1224. Here is the list of services that require prior authorization.
Please note: The Security Health Plan prior authorization requirements apply regardless of whether we are your primary or secondary coverage. In addition, prior authorization decisions can be made by Security Health Plan or vendors contracted by Security Health Plan, such as eviti, eviCore, Prime Therapeutics Management, Northwood or other vendors.
Even if you are being seen for an injury believed to be work-related and covered by workers’ compensation, you should seek prior authorization to ensure coverage in the event the workers’ compensation claim is denied.
Our prior authorization review process includes the IQ Transparency medical decision-making tool
Security Health Plan uses the InterQual® IQ Transparency Tool to provide enhanced clinical detail during the medical decision-making process. This tool allows a person’s severity of illness, coexisting conditions and complications to be considered during the prior-authorization process.
The InterQual® criteria used by Security during the process are clinically based on best practices, clinical data and medical literature and are updated continually and released annually. Security also recognizes criteria can never address all issues nor can it apply to every patient in every situation. Use of the criteria never replaces clinical judgment.
To view clinical content on the InterQual® Transparency Tool, visit Change Healthcare (part of Optum®) and follow these steps:
1. Create a One Healthcare ID.
2. Once logged in, you can select the subsets from the drop-down menu.
3. Under product, select the appropriate subsets: LOC: Acute Pediatric, CP: Imaging, etc.
Security Health Plan clinical medical policies
In certain cases, Security Health Plan uses clinical medical policies to assist with evidence-based decision-making process. Assess our clinical medical policies.
Medical benefit drugs
Drugs that are injected or infused while you are in a provider's office, a hospital-based outpatient center, or an ambulatory surgical center are called medical benefit drugs. (Such drugs fall under Part B for members with Medicare.) Medical benefit drugs may require prior authorization and may be updated quarterly. In addition, home infusion services may also require prior authorization.
For more information about prior authorization for medical benefit drugs, call our Customer Service Department at (844) 293-9624 (TTY: 711).
Home infusion drugs
Some medical benefit drugs are eligible for home infusion coverage. Some home infusion services may also require prior authorization.
Services that may require prior authorization depending on your plan
You can view the list of services that require prior authorization in Spanish.
- Abdominoplasty
- Acute rehabilitation admission
- Air ambulance transport (non-emergent)
- Amino acid formula
- Autologous cultured chondrocytes
- Back surgeries at all levels
- Breast reconstruction post mastectomy not related to cancer
- Chemotherapy infusions
- Clinical trials
- Cosmetic and reconstructive surgery
- Diabetes Durable medical equipment
- Durable medical equipment
- Elective inpatient admission including acute medical, behavioral health and surgical
- Elective outpatient procedures such as, but not limited to: knee arthroscopy, back surgeries at all levels
- Enteral feeding
- Femoroacetabular impingement surgery
- Genetic testing
- High end imaging (CT, PET, MRI)
- High end imaging cardiac imaging and elective heart catheterization
- Hip surgery
- Home healthcare services including but not limited to skilled nursing, physical therapy, occupational therapy, speech therapy
- Hyaluronic acid
- Infuse bone graft
- Infusion therapy
- Inpatient hospital stay and residential treatment
- Intravenous iron therapy
- Knee surgery
- Lipectomy
- Long term acute care admission
- Non-emergent ambulance transport
- Oral appliance for obstructive sleep apnea
- Out-of-network provider request
- Pain management
- Panniculectomy
- Pharmaceuticals - specialty medications
- Prosthetic orthotic services
- Radiation oncology therapy
- Radiology services - CT, PET, MRI and MRA
- Reduction mammoplasty
- Rhinoplasty
- Septoplasty
- Skilled nursing facility admissions
- Spinal cord stimulation
- Spine and joint surgery
- Swing bed admission
- Synagis
- Technologies not commonly accepted as standard of care
- Transplants including stem cell/bone marrow, solid organ and gene therapy
- TMJ surgery
Prior authorization annual metric reporting
To comply with the CMS Interoperability and Prior Authorization final rule, Security Health Plan is required to annually report aggregated prior authorization metrics on our website. Specifically, this includes a list of all medical items and services (excluding drugs) that require prior authorization, as well as data on prior authorization requests for those items and services (e.g., approvals, denials, etc.) over the previous calendar year. Publicly reporting these metrics promotes transparency and accountability, helps members understand prior authorization processes, and enables providers to evaluate payer performance. In addition, metrics can be used to compare plans, programs and payers.
2025 prior authorization metrics for Individual, Medicaid and Medicare