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Prior Authorization (Part C)

What is Prior Authorization?

Prior Authorization is a process which must be completed before you get some services. Some services must get prior authorization, also called Prior Approval, before the plan will pay for it. Your doctor will make the request, you can make the request too. We will need Medical records and notes from your doctor. Other information that shows why you need the item or service will be needed. Call your doctor if you need this information.

What services require Prior Authorization?

To get a list of services that require prior authorization, please contact IlliniCare Health at 1-877-941-0482. Hours are 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711.

For out-of-network services you must get prior authorization. You do not need prior authorization for emergencies. Out-of-area urgent care or dialysis does not need prior authorization.

What are the steps for getting Prior Authorization?

You may get prior authorization by calling IlliniCare Health at 1-877-941-0482 (TTY: 711). Providers need to send prior authorizations through the web portal, by phone or by FAX.

You will be told if we approve the service before 72 hours after we get your request. This is what we call a Fast decision (Expedited).

You will be told no later than 14 calendar days for all other requests.

If we find that your health may be in danger we will hurry your request.

We will tell you what we decide in writing or by telephone. In the case of an emergency, you do not need prior authorization.

Prior authorization is not a guarantee of payment. The plan has the right to review the service for medical need after you receive the services. The member must be eligible for services. Some services have limits. Some benefits have exclusions.

Important Information About Your Appeal Rights

There are 2 kinds of appeals:

  • Standard Appeal – An appeal is the process to review a decision you may not like. If you do not like the choice we have made, you have the right to make an appeal. We will review our decision and let you know what we decide. You will get a written answer on standard appeal 15 business days after we hear from your appeal. We may take longer if you ask for more time, or if we need to know more about your case. We will tell you if we are taking extra time and will explain why more time is needed. 

If you had to pay for a service and want to be paid back, you can ask us. If your appeal is to pay you back, we will tell you in writing. We will tell you in 60 days.

  • Fast Appeal – You will get an answer within 24 hours after we get your appeal.  You can ask for a fast appeal if you or your doctor think your health could be in danger.

If your doctor asks for a fast appeal, you will get one.

If you want a fast appeal but your doctor did not ask, we may not approve it. 

If we don’t give you a fast appeal, we’ll give you an answer in 15 business days.

How to ask for an appeal with IlliniCare Health.

  1. Step 1: To ask for an appeal you have to tell us. It can be from you, your representative, or your doctor.
  2. Step 2: Write, mail, fax, deliver your appeal or call us.


For a Standard Appeal:

IlliniCare Health
ATTN: Appeals and Grievances
7700 Forsyth Blvd
St. Louis, MO 63105

Phone: 1-877-941-0482 (TTY: 711)
FAX: 1-844-273-2671

If you ask in writing, your appeal must include your:

  • Name
  • Address
  • Member number
  • Reasons for the appeal
  • Medical records, notes or a letter from your doctor.
  • Other information that shows why you need the item or service. Call your doctor if you need this information.

You can ask to see these pieces before we decide. It will not cost anything to you.

If you ask for a standard appeal by phone, we will send you a letter telling you what you told us.

For a Fast Appeal:

Phone: 1-877-941-0482 (TTY: 711)
FAX: 1-844-273-2671