Member FAQs

Member FAQs

Authorization Reviews & Decisions

Why do certain covered services require pre-approval?

Certain covered services require prior authorization (pre-approval) from your PCP's affiliated medical group or from WHA in some cases, to make sure they are paid under your health plan benefits.

How do I get pre-approval and who makes those decisions?

Your PCP should know when pre-approval is needed. PCP staff will notify your medical group or WHA when you need to see a specialist or get another service that requires pre-approval. Decisions are made by qualified medical professionals (doctors and nurses), but only experienced physicians can deny or modify a requested service.

Which services do not require pre-approval?

You do not need pre-approval for initial emergency room treatment. Members can self-refer within the network for their annual eye exam (when covered) and OB/GYN visits. You just need to make sure the specialist is in WHA's provider network. View the Provider Directory for participating network specialists or contact Member Services for assistance.

How long does it take to get pre-approval?

A decision to pre-approve, modify or deny a specialty or service referral request must be made within certain timeframe(s). These are based on the urgency of your medical condition and treatment needs, but most decisions are made within five working days of receiving necessary information to make the decision. If fast handling of your case is needed due to urgent medical needs, your doctor may ask for an expedited review. These will be completed by the plan as soon as possible based on your situation, but no later than 72 hours of receipt of the request and pertinent information to make a decision.

The site you are transferring to is not hosted by WHA. WHA's Terms of Use and internet Privacy Practices do not apply to your use of this linked site. Please review the policies on privacy and terms of use for the linked site. WHA does not control the accuracy, completeness, or timeliness of the content on the linked site.