Article

Prior Authorization

There are some services that Gateway Health Plan® must approve before you can get them. The doctors and nurses who work for Gateway are available to help your doctor choose the best way to take care of you. These doctors and nurses are part of Gateway’s Health Services Department. They make decisions about the care that is most likely to help you by using specific guidelines for medical decisions. The guidelines are based on whether the service is medically necessary as defined by the Department of Public Welfare (DPW). There is no extra payment given to these doctors and nurses no matter what they decide about your care.

If you need a service that must be approved by Gateway before it is done, your doctor will call the Health Services Department to get an approval. The doctors and nurses in Health Services will look at all the medical facts given by your doctor within certain time limits to decide if this service is the best way to take care of you.

For a list of services that need to be approved, refer to your Member Handbook or call Gateway’s Member Services department at 1-800-392-1147.

There may be other services that need to be approved by Gateway first. Call Member Services at 1-800-392-1147 to see if the service you need requires prior approval.

When Gateway denies, decreases, or approves a service or item different than the service or item you requested, you will get a letter (notice) telling you Gateway’s decision. This letter contains information on how to contact Gateway if you disagree with the decision. This information can also be found in the Member Handbook.