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Health Matters

News and information for King County employees and their families

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Know when to preauthorize your medical care

When you’re covered by SmartCare Connect, your Group Health doctors preauthorize your medical care without you having to think about it. But, in the KingCareSM plan, it’s not so straightforward.

Regence Blue Shield automatically pays for most of the services you routinely receive from a network provider. Routinely covered services include preventive care, office visits, immunizations and out-patient mental health care. However, there are a number of services that require preauthorization from Regence before you can receive treatment. And, if you don’t get the preauthorization, you may find yourself footing the bill.

When you see a network provider, your provider obtains preauthorization from Regence for your care. That preauthorization means your benefits will be paid according to plan provisions and limits.

Know when to preauthorize your medical careWhen you see an out-of-network provider, you or your provider must contact Regence for preauthorization. If your provider contacts Regence on your behalf, you should follow up with Regence to confirm that the service has been preauthorized and will be covered.

Services that require preauthorization include:

  • durable medical equipment
  • growth hormones (billed through Regence)
  • home health care
  • hospice care
  • injectable prescription drugs, with certain exceptions such as insulin, Depo-Provera and some others (billed through Regence)
  • inpatient chemical dependency treatment
  • inpatient care alternatives
  • inpatient hospital care, other than for most stays in connection with childbirth
  • inpatient mental health care
  • neurodevelopmental therapy for covered children age six and younger
  • obesity surgery or other procedures, treatment or services, such as gastric intestinal bypass surgery (preauthorization requires that the procedure is medically necessary and that a physician-supervised weight management and exercise program has been successfully completed)
  • orthognathic surgeries (to correct jaw abnormalities or malocclusions when medically necessary)
  • skilled nursing facility care
  • TMJ disorders
  • transplants.

Whether you see a network or an out-of-network provider, Regence must be notified at least seven days before you have surgery or are admitted to a hospital on a non-emergency basis, except for childbirth. Before your admission, be sure to confirm with the hospital that your stay has been preauthorized.

You must call Regence within 24 hours from the beginning of your admission, or as soon as reasonably possible, for:

  • accidents
  • emergencies, including detoxification
  • involuntary commitment to a Washington state mental hospital
  • maternity admissions.

To obtain preauthorization for non-emergency care, ask your physician to contact Regence.

When calling Regence, be prepared to supply these details:

  • admission date
  • diagnosis or surgery
  • employer name (King County)
  • employee name and unique identifying number assigned by KingCareSM
  • hospital name and address or phone number
  • patient name, address and birth date
  • physician name and address or phone number
  • proposed treatment plan, including length of stay and discharge planning needs.

If your care isn’t preauthorized and Regence determines that your care wasn’t medically necessary, Regence may pay only a portion of the charges or none at all. When in doubt, particularly when the service you’re going to receive may be expensive, pick up the phone and call Regence to verify that your care will be covered.

Contact information

You can find contact information on the back of your Regence medical card. That information is also shown here:

  • For preauthorization for most services, call 1-888-376-6544, Monday–Friday,  5 a.m.–9 a.m. and 10 a.m.–5 p.m. Pacific Time
  • For mental health and substance abuse preauthorization, call 1-800-868-1032, Monday–Friday, 5:30 a.m.–2:00 p.m. Pacific Time. An answering service for after-hours calls will ask the on-call representative to return your call.