Clinical Information for Prior Authorization

Requests for prior authorization of services and materials are reviewed by our clinical review team of optometrists and ophthalmologists. During the clinical review process, the team evaluates the requested services and materials for medical necessity based on evidence-based criteria and/or plan covered benefits. If the clinical review team identifies missing information, the utilization management department will attempt outreach to the requesting provider if state and federal timeframes for issuing a determination allows. The utilization management team will request the specific additional information required to make a determination. To more efficiently process a prior authorization request, some of the clinical information that may be helpful in processing a request is listed below. Although not all-inclusive due to state, federal, and plan-specific requirements for some plans, clinical criteria used for review can be found at https://versanthealth.com/policies/.