We get it. You have a nagging pain in your back that just won’t go away, so you go see your doctor, who sends you for an X-ray. Unfortunately, the X-ray doesn’t show a thing, so the next step might be a CT-scan or even an MRI, and you may even have to see a specialist depending on the test results.
You think you’re all set, but then the doctor says, “We’ll call you to set up an appointment after we get prior approval from your insurance company.”
Wait. What? You think, “I can barely stand up and now I have to go through this red tape?”
Yes, you probably do.
Community Health Options understands that getting medical care is nerve-wracking enough, so you won’t need a referral for the specialists, even though the specialist may require one from your doctor. But Members do need Prior Approvals for certain services and prescriptions before getting treatment (Prior Approvals are also sometimes called Prior Authorization, Precertification or Preauthorization).
While it might seem like getting approval delays care, Community Health Options, as a nonprofit insurer, uses Prior Approvals to understand its Members needs and to facilitate care. Clinicians rely on evidence-based care guidelines to approve the care Members need, while protecting against the care they don’t. Importantly, approval ensures that a Member’s health plan will cover the service or procedure.
Community Health Options Chief Medical Officer Dr. Lori Tishler calls it “utilization management with heart. Our goal is to get someone what they need, so we’re constantly looking for ways to make things easier for patients and providers.”
When "No” means “Yes”
In some cases, clinicians at Community Health Options may even suggest more care than the initial request. For example, a request for a certain kind of outpatient behavioral health care was denied because the Community Health Options team saw a need for inpatient care and worked with the provider to get that higher level of care delivered.
In almost every case, the company responds to urgent requests within 24 hours and more routine requests within 72 hours, but usually less. Requests may be denied if clinicians at Community Health Options need more information about the need for a certain procedure.
And in 2023, the company dropped Prior Approval requirements for about 5,000 codes primarily across three categories—ultrasounds, obstetrics ultrasounds and services related to treating fractures. A code review committee continues to review and revise Prior Approval requirements.
A right to appeal
Members and providers always have the right to appeal a Prior Approval decision, whether for a medical benefit or prescription. In many cases, additional information helps to move things along, and sometimes providers will talk to an independent doctor for a final decision about the best solution.
Members with questions or concerns about Prior Approval can call the Community Health Options’ Maine-based Member Services team number on the back of their Member ID card from 8 a.m. to 6 p.m., Monday through Friday.
When it comes to health insurance, the strength of a health plan’s network helps to determine its value, and you want to be sure the care you need is never far away. That’s why Community Health Options’ network stretches across Maine, and includes many providers in New Hampshire, Vermont and even Massachusetts, comprising 48,000 clinicians, hospitals and pharmacies—no matter which plan you choose.
When you buy auto insurance, you really don’t give much thought to who might fix your car if you have an accident, because you’re hoping you never need it. But health insurance is different. You’ll use it no matter what, whether you are healthy and need screenings to stay that way, or need care to manage chronic illness, behavioral health issues or complex care.
So, when it comes to health insurance, the strength of a health plan’s network helps to determine its value, and you want to be sure the care you need is never far away.
That’s why Community Health Options’ network stretches across Maine, and includes many providers in New Hampshire, Vermont and even Massachusetts, comprising 48,000 clinicians, hospitals and pharmacies—no matter which plan you choose. Notably, all Maine hospitals*, most in New Hampshire and Centers of Excellence in Massachusetts are all in-network and considered preferred for in-patient services on tiered HMO plans. Additionally, if you live outside of Maine part-time, often travel across the country or have a child away at college, national plans offer providers through our partnership with First Health®. And most recently, Community Health Options has been adding emergency medical services to its network, giving Members better EMS coverage, thanks to the adoption of a 2023 Maine law making that possible.
Coverage for virtual care includes telehealth options that begin with your own providers if they offer that service. If you are 18 or older—and looking for a primary care provider—you can choose a traditional in-network provider or opt for a virtual-first primary care team through Firefly Health. Firefly provides 24/7 access to a primary care team, anytime, anywhere, making it easier to access care right from your cell phone, whether you need preventive and routine care, or help managing more complex issues. Learn more about Firefly Health and download the app here.
Members also have access to urgent care telehealth sometimes. So, when you’re hurt or sick, or need care right away, of course head to the emergency room or call 911 if your condition is serious or life-threatening. However, you can save time and money using Amwell 24/7 for urgent care telehealth from the comfort of your home—at $0 cost share on non-HSA plans, and $64 on HSA plans ($0 after deductible). Amwell also offers behavioral health services like therapy and psychiatry. Scheduling is easy and you can do so online after registering, or by calling (844) 733-3627 for support.
Perhaps most important, Community Health Options supports its network with Maine-based care teams who help Members get access to providers, including virtual care, and who have on-the-ground knowledge of local resources.
Community Health Options’ care teams are available for any question through our Member Services team. If you have questions, please call (855) 624-6463 between 8 a.m. and 6 p.m., Monday through Friday.
