Prior authorization is the process of obtaining written approval from Aspirus Health Plan for services or products before they are received. The prior authorization form is a document submitted to Aspirus Health Plan by your medical care provider. In reviewing a prior authorization request, proposed services are subject to all plan provisions, including medical necessity requirements and plan exclusions, among others.
Be sure prior authorization requests are approved before obtaining care. It is ultimately the member’s responsibility to make sure prior authorization forms are submitted and approved by Aspirus Health Plan prior to receiving care.
If you have questions about prior authorizations, please call the number located on your ID card or contact Member Services at 866.631.5404.
Aspirus Health Plan encourages that you review your health plan for specific authorization requirements, excluded services/treatments, and referral requirements.
If your prior authorization is approved, the non-participating provider reimbursement value will apply to out-of-network providers and services. The amount the plan pays is the allowed amount for any covered service. But if an out-of-network provider charges more than the allowed amount, you may have to pay the difference.
Here’s an example: You go to an out-of-network hospital, which charges $1,500 for an overnight stay. If the allowed amount is $1,000, you may have to pay the $500 difference.
Different standards apply depending on whether the admission is acute or elective.