Precertification list change notification for Virginia for September 1, 2023

Precertification responsibility

The ordering or rendering provider of service is responsible for completing the prior authorization process.

HMO plans

Services that require precertification will be denied if rendered without the appropriate prior authorization for in-network providers. HMO members may not have benefits for non-emergency services rendered outside of the network and are subject to review and may be denied.

PPO plans

Precertification for services requiring prior approval is highly recommended. If not completed in advance, a pre-payment review of the claim will occur and may result in a denial of claim reimbursement.

EPO plans

Precertification for services requiring prior approval is highly recommended. If not completed in advance, a pre-payment review of the claim will occur and may result in a denial of claim reimbursement. No out-of-network benefit is available with the exception of ER/urgent care and authorized services.

To request precertification with the Virginia plan:

• Access Availity* at availity.com.
• For maternity, medical, and/or surgical precertification, call the number listed on the back of the member’s ID card.
• For mental health and substance use precertification, call 800-755-0851. Professionals are available 24 hours a day, seven days a week.

The following services will be added to precertification for the effective dates listed below.