Prior Authorization

HAP CareSource™ evaluates prior authorization requests based on medical necessity, medical appropriateness and benefit limits.

Continuity of Care

HAP CareSource will coordinate continuity of care for members who have existing care treatment plans that include scheduled services with nonparticipating health partners or who transition to or from another payer including those members identified as having special health care needs. For continuity of care request approvals for nonparticipating primary care providers, 30 days of service will be allowed for the nonparticipating health partner to transfer care to the network primary care provider.

The provider will have to provide evidence of the authorization of the services from the received verification of services. HAP CareSource will provide an authorization from the date of eligibility with HAP CareSource to the end of the already approved service. The provider will have to submit a request for any additional services for review of medical necessity outside these dates of service prior to transition.

HAP CareSource will need to be contacted via phone at 1-833-230-2102, as there needs to be an authorization in our system that matches the billed services.

Services That Require Prior Authorization

Please refer to the Procedure Code Lookup Tool to check whether a service requires prior authorization. All services that require prior authorization from HAP CareSource should be authorized before the service is delivered. HAP CareSource is not able to pay claims for services in which prior authorization is required but not obtained by the provider.

HAP CareSource does not require referrals to see an in-network specialist. The specialist may require a referral from the member’s PCP. Some services and procedures require prior authorization. Referrals and prior authorizations must be obtained prior to services being rendered. 

Prior Authorization Procedures

Urgent requests should be marked urgent. Urgent requests will be accepted when the member or their physician believes waiting for a decision under the standard time frame could place the member’s life, health or ability to regain maximum function in serious jeopardy. Referrals and prior authorization for services should be made to in-network providers whenever possible. Contracted providers can be found in our online Provider Directory.

Written prior authorization requests should be submitted on the Prior Authorization Request Form.

Nonparticipating Providers

Pharmacy Prior Authorization

Some drugs may require prior authorization before they will be covered. Please refer to the Pharmacy page to review these requirements.

Dental Prior Authorization

Our dental provider manual and other dental resources are available on the Delta Dental Provider Web Portal.

Advanced Imaging Prior Authorization

Ordering physicians must obtain prior authorization for the following outpatient, non-emergent diagnostic imaging procedures:

  • MRI/MRAs
  • CT/CTA scans
  • PET scans

Ordering providers can obtain prior authorization from Evolent, formerly known as NIA, for imaging procedures at RadMD’s website.

Obtaining a Remittance Advice (RA)

To access your RA, log in with your username and password.