Did you know?

Grande expanded prior authorization to outpatient services on the UMR medical plan. Failure to obtain prior authorization may result in increased out-of-pocket costs.

How to complete?

You or your healthcare provider can call 1-800-826-9781 to verify the level of benefits available. You can receive verification on what services will be covered and the amount, if any, your Grande medical plan will pay towards the cost of care.

What is Prior Authorization?

Prior Authorization is the process of determining benefit coverage prior to a service being rendered to an individual member. A determination is made based on Medical Necessity criteria for services, test or procedures that are appropriate and cost-effective for the member. The member-centric review evaluates the clinical appropriateness of requested serves in terms of the type, frequency, extent and duration of stay.

 

Procedures that require a Prior Authorization:

  • Inpatient hospitalization and surgeries
  • Inpatient rehabilitation and behavior health
  • Skilled nursing facility
  • Home healthcare
  • Durable medical equipment
  • Radiology services such as MRA, MRI, PET and CT scans
  • Chemotherapy and radiation
  • Dialysis
  • Occupational, speech or physical therapy
  • Transplant and transplant related services
  • Reconstructive surgeries and cosmetic procedures
  • Genetic testing
  • Clinical trials and experimental procedures
  • Hormone therapies
  • Hospice
  • Qualifying clinical trials
  • Inpatient stays in Hospitals or Birthing Centers that are longer than 48 hours following normal vaginal deliveries or 96 hours following Cesarean sections.
  • Prosthetics over $1000
  • Organ and tissue transplants

 

For more information or questions you can refer to the UMR Summary Plan Description on www.grandehealth.com or by contacting the benefits department at healthandwellness@grande.com.