For pre-service requests, it is OrthoNet’s goal to review the supporting clinical data, verify eligibility/benefits, render a determination, and assign an authorization number, if approved, within one (1) to two (2) business days following the receipt of all necessary information. (For urgent pre-service Medicaid requests, this will occur within 72 hours of receiving the request.) All utilization management decisions meet accreditation (National Committee for Quality Assurance (NCQA)) and regulatory time frames. Providers are notified on the day the decision is made, and given the following information, both verbally and via fax:
- Authorization number
- Number of approved visits and/or units
- Next review date
For procedures performed at locations other than the clinician’s office, OrthoNet also notifies the facility.
Prior approvals are valid for 90 days from the date they are issued.
To check on the status of a prior approval request, providers may contact OrthoNet’s Customer Service department at 844-730-8503, Monday through Friday, 8:30 a.m. to 5:30 p.m.
Note: Anauthorization is not a guarantee of payment and it is contingent upon the member’s benefits, contract limitations, and eligibility at the time of service.