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Prior Authorization

The prior authorization process is when some services need approval before your child can get the service. You or your child’s provider will need to send us medical documents to review to show the requested services are medically necessary. For services that require prior authorization, see the Enrollee Handbook or call Keystone First – CHIP Enrollee Services at 1-844-472-2447 (TTY 711).

What Does Medically Necessary Mean?

Medically necessary means that a service, item, or medicine does one of the following:

  • It will, or is reasonably expected to, prevent an illness, condition, or disability.
  • It will, or is reasonably expected to, reduce or improve the physical, mental, or developmental effects of an illness, condition, injury, or disability.
  • It will help your child to get or keep the ability to perform daily tasks, taking into consideration both your child’s abilities and the abilities of someone of the same age.

If you need any help understanding when a service, item, or medicine is medically necessary or would like more information, please call Enrollee Services at 1-844-472-2447 (TTY 711).

Utilization Review Process

Utilization Management is a process that we use to work with you, your child’s providers, and others to provide your child medically necessary services. The main goal of utilization management is to provide quality, cost effective healthcare in the most appropriate setting for the services required. Some services may require prior authorization to allow us to make sure the service is medically necessary. For questions about the utilization review process please call Keystone First – CHIP Enrollee Services at 1-844-472-2447 (TTY 711).

How to Ask for Prior Authorization

  1.  Your child’s PCP or other health care provider must give Keystone First – CHIP information to show that the service or medicine is medically necessary.
  2. Keystone First – CHIP clinical reviewer or pharmacists review the information. They use clinical guidelines approved by the Department of Human Services to see if the service or medicine is medically necessary.
  3. If the request cannot be approved by a Keystone First – CHIP clinical reviewer or pharmacist, a Keystone First – CHIP doctor will review the request.
  4. If the request is approved, we will let you and your child’s health care provider know it was approved.
  5. If the request is not approved, a letter will be sent to you and your child’s health care provider telling you the reason for the decision.
  6. If you disagree with the decision, you may file a complaint or grievance, and/or request an external review. See the Enrollee Handbook for information about complaints, grievances, and external reviews. You may also call Enrollee Services at 1-844-472-2447 (TTY 711) for help in filing a complaint or grievance and/or requesting an external review.

If you need help to better understand the prior authorization process, talk to your child’s PCP or specialist or call Enrollee Services at 1-844-472-2447 (TTY 711).

If you or your child’s provider would like a copy of the medical necessity guidelines or other rules that were used to decide a prior authorization request, you can call Enrollee Services at 1-844-472-2447 (TTY 711). Your child’s provider can call Provider Services at 1-800-521-6007.

Services that need prior authorization

For a complete list of services, items, or medicines that need prior authorization, please see the Enrollee Handbook. If you have questions about the prior authorization process, please talk with your child’s doctor. You can also call Enrollee Services at 1-844-472-2447 (TTY 711).