Within 72 hours of receipt of a request, the member will be notified by phone, or in writing, of the prior authorization determination. If a provider fails to follow the health plan’s procedures for filing the prior authorization, the provider will be notified within five days upon receipt of the request.
To obtain coverage of a prescription requiring prior authorization in an urgent care situation, providers may contact Pharmacy Management at (800) 897-1923 or (608) 775-8007. The time frame for an urgent review and determination will not exceed 24 hours from receipt of the request.
The Gundersen Health Plan provides the practitioner with information to understand and decide whether to appeal a decision to deny coverage. The following information is included in all denial notices:
- The specific reason for the denial in understandable language
- Reference to the specific plan provisions on which the denial is based
- Instructions for filing a grievance/appeal regarding the denial and independent external review (if applicable)
You may obtain a copy of the criteria, clinical guidelines, or benefit provisions used for making a decision. Please contact us by phone at (800) 370-9718 ext. 58022, or (608) 775-8022, or send your request to us at the address listed above. Gundersen Health Plan is staffed with a full time pharmacy director who is able to discuss medical necessity decisions. In the event the pharmacy director is unavailable, our medical director or an associate medical director can address questions regarding determinations.