Utilization review

Learn about the utilization review process at LifeWise.

Prior authorization

Many services require review before they're provided. Whenever possible, submit a review request before providing the service. This helps us pay claims faster with no unexpected cost to you or the member after the services are provided.

Sometimes a service requires prior authorization. If you don't get a prior authorization, it could result in a payment penalty for you or the member. Note: You can't submit a prior authorization request by phone.

When a service requires pre-service review, there isn't a penalty, but we'll hold the claim and ask for medical records.

Individual Plans use a new code list, prior authorization tool, and online submission tool Identifi (not eviCore) for outpatient rehabilitation services. Sign in for access to Individual Plan tools.

Find out if a code needs review

To see if a prior authorization or pre-service review is required, check our code list or sign in to get member-specific information using the prior authorization tool. Use the 2024 code list for dates of service starting Jan. 5, 2024.

Submit a prior authorization request

Sign in and submit a request with the member’s ID number using our prior authorization tool.

Read our step-by-step guide on how to use the prior authorization tool.

It takes 1-5 business days for LifeWise to authorize your use of the tool. Signing into our secure site automatically triggers the authentication process and you will receive a confirmation email once access is granted. During the delay, you can fax a prior authorization request.

You can also complete and fax our request form to 888-613-1497. Be sure to include the needed supporting documentation (see our code list for details).

Check prior authorization review status

Sign in to the online prior authorization tool to get the status of a request. You can search for requests by reference number, requesting provider, or patient name. You can also edit a submitted prior authorization request in the tool.

For more information about our online prior authorization tool, read our step-by-step guide.

Types of services

Individual plans use one prior authorization request form for all services including durable medical equipment (DME) and provider-administered infusion drugs.

For advanced imaging, prior authorization requests must go through Carelon (formerly AIM). Learn more about Carelon Medical Benefits Management.

Common services that require prior authorization

We require review for procedures or services that could be a health and safety issue for our members. This includes most planned inpatient services, some planned outpatient DME, and many in-office pharmacy services including injectables, IVs, and biologics.

Common services that require prior authorization include, but are not limited to:

All planned inpatient stays
Admission to a skilled nursing facility or rehabilitation facility
Behavioral health including admissions to residential treatment centers, partial hospitalization, and intensive outpatient programs
Applied behavioral analysis therapy (ABA)
Non-emergency and elective air ambulance services
Most outpatient services
Certain organ transplants
Purchase of supplies, appliances, DME, and prosthetic devices
Provider-administered drugs

Admission and discharge notifications

For inpatient stays, you can fax the patient’s hospital face sheet to our utilization management team at 888-613-1497 or you can submit an admission and discharge notification. You don’t need to send a hospital census. Submitting a face sheet or notification helps you get your claims paid correctly and on time.

Trying to see if a prescription medication requires prior authorization? Check out Drugs Requiring Approval.

Emergencies and extenuating circumstances policy

If an emergency prevents you from getting prior authorization, you must notify us within 48 hours following onset of treatment, or as soon as is reasonably possible.

We know situations arise that can make it impossible for you to get prior authorization before treating a patient, or to notify us within 24 hours of admission. In these situations, please contact us before submitting a claim. Follow the recommended practices detailed in the extenuating circumstances policy so that the claim isn't automatically denied.