Prior Authorization Instructions

The following surgical procedures require pre-authorization by EyeMed:

Please follow the instructions listed below when submitting an online pre-authorization request:

To submit a prior authorization request, please complete the following tabs in their entirety. All required fields on the current tab will need to be completed before moving to the next tab. Please use the Back and Next buttons for navigation instead of the browser buttons.

1. Member Info Tab:  You must include the follwoing member related information
   • First Name
   • Last Name
   • Date of Birth - This can not be greater than the current date
   • 10 Digit Phone Number
   • Identification Number
   • Name of the Insurance Plan
   • Timeline for request:
     
     • Expedited (72 hours) - This should only be selected if the procedure is scheduled to occur in less than the standard 14 days from the current date.
     • Standard (14 days)
     • Emergency (30 days) - This should only be selected if the procedure could not wait to obtain prior authorization and has already occured.
2. Provider Tab:  This is your information.
   First Name
   • Last Name
   • National Provider Identifier (NPI)
   • National Provider Identifier (NPI)
   • Provider Tax ID
   • Eyemed Provider ID
   • Office Contact Name - This should be someone who is available to answer questions if needed
   • Office Address, City, State and Zip
   • Office Phone and Fax Number - Must be a 10 digit number with or without dashes or parentheses.
   • Office Email Address - Valid email address which is monitored and can be used to contact somone in your office in case there are questions.
3. Facility Tab:  Provide information regarding the faciliy where the procedure will take place. The below information will be needed if the procedure was not completed in your primary office facility.
   Facility Name
   • Facility Address, City, State and Zip
4. Procedure/Diagnosis Tab:  This will cover the medical information. Some fields may not appear until a procedure code is selected.
   • Date Patient Last Seen - This can not be greater than the current date
   • Procedure Code
   • Type - RT (Right), LT (Left), 50 "both"
   • Diagnosis Code - You can select as many of these which are applicable to the procedure being performed.
   • Date of Service - This must be no more than 180 days in the past or the future.
   • + Procedure - check this box if you need to submit a second procedure on the same request.
   • Additional Commentary or Medical Rathionale - Enter any additional information which you believe would be helpful in processing your request.
   • Attachment - Include medical records, eye exam information, appropriate test results and photos.
   • Checklist - Please review the items on the checklist to ensure you have inluded all necessary documentation with your request.
5. E-signature Tab:  Once you've completed all tabs, read the attestation and enter your e-signature.

After you have completed all the tabs use the Submit button to send your request. You will recieve a success message when the request is received successfully. The screen will be reset to allow you to enter another request if needed.

Once EyeMed has received the request it will be reviewed by the Utilization management team including a clinical reviewer, if needed. If necessary, you may be contacted for additional information. If a request for pre-authorization meets medical necessity guidelines, an approval number will be issued and the provider will receive an authorization letter. If a request for authorization does not meet the medical necessity guidelines, the letter will contain appeal information.

For services rendered on an emergency basis, prior authorization for the above-referenced surgical procedures is not required. Providers must submit a request via the portal or notify EyeMed by telephone on the next business day following the provision of the emergency care by calling 1-866-652-0038. Medical records related to the emergency care rendered must be attached to the case in the portal or faxed to EyeMed at 1-513-492-6739.

Note:   Providers must use participating health plan facilities and receive authorization for the facility and anesthesia from the health plan. If an out-of-network facility is to be used, a facility authorization must be obtained directly from the health plan.