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Authorization Requirements

For some services, utilization review is necessary to determine the medical necessity and appropriateness of a covered health care service for Superior HealthPlan’s managed care members.  For those services, utilization review is performed before (prior authorization), during (concurrent review) or after (retrospective review) the service is delivered.

Authorization Lists

A listing of services that require authorization prior to the delivery of service, concurrently while the service is being provided, or retrospective of the provision of the service for Medicaid, CHIP, Health Insurance Marketplace, and Medicare Programs may be accessed by visiting the links below:

Prior Authorization Requirements effective September 1, 2019 and after:

The effective date of prior authorization requirements implemented on or after September 1, 2019 for specific codes can be accessed at the links below:

Authorization Forms

To access Prior Authorization Request forms for applicable services, visit Superior’s Provider Forms webpage.

Authorization Clinical Documentation Requirements

This listing provides the clinical documentation required to be submitted with authorization requests for prospective, concurrent and retrospective utilization review. requests for medical necessity review and approval through Superior’s contracted Utilization Review Agents (URA).

Clinical Documentation Requirements for Health Care Services that Require Authorization (PDF)

Clinical and Clinical Payment Policies

To access Superior’s clinical and clinical payment policies, visit Clinical, Payment & Pharmacy  Policies. Refer to the Authorization Procedures and Requirements section below, for more information on authorization procedures and requirements, including screening criteria and the use of these proprietary clinical policies during utilization review (for applicable services that require authorization).  

Annual Prior Authorization Summaries

Authorization Process, Procedures and Protocols

Please reference the sections below for additional prior authorization requirements and information.

Prior Authorization News