Health First Commercial Plans, Prior Authorization

Health First Commercial Plans, prior authorization rules are often service-specific rather than universal, so the safest workflow is to confirm the requirement in the payer's provider resources before scheduling or submitting care. The notes below summarize the most actionable provider-side guidance captured in the research set for this payer.

At a glance

• Officially, some services require prior authorization, and provider-directory materials say local network providers have the information on services that require prior authorization and the steps to obtain approval. The publicly accessible sources located here do not provide a complete service-by-service list or a usable submission workflow, so the operational details remain partially unsupported.
• Publicly accessible official pages found here do not expose the complete prior-authorization grid or the exact submission form/process.
• Requirements may vary by line of business, benefit design, and whether the service is medical or pharmacy.

Where to verify prior authorization requirements

• Verification resource 1
• Verification resource 2
• Verification resource 3

How to submit prior authorization requests

• Not clearly stated in the accessible official sources

• Provider portal / online tools implied by official provider portal and file-exchange portal

• Phone to Customer Service for guidance

• Submission resource 1

Information commonly required

• Specific service/procedure being requested
• Member/plan identification information
• Supporting clinical documentation from the provider
• For drug exceptions, a statement from the provider supporting the request

Turnaround notes and caveats

• For Part D formulary/tiering/utilization exceptions, the plan states decisions are generally due within 72 hours after receiving the prescriber’s supporting statement, or within 24 hours for expedited requests if granted.
• No comparable public turnaround time was located for medical prior authorization requests in the accessible official sources.
• Publicly accessible official pages found here do not expose the complete prior-authorization grid or the exact submission form/process.
• Requirements may vary by line of business, benefit design, and whether the service is medical or pharmacy.

Provider resources

• Provider Resources (official)
• HFHP File Exchange Portal (official)
• Access My Account / Provider portal entry point (official)
• Provider Directory (commercial plans PDF) (official)
• Provider Directory (Medicare provider directory PDF) (official)

Sources