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Predetermination & Prior Approval for Health & Dental Claims
To help keep our plan sustainable and affordable, certain health and dental claims—including some medications, supplies, devices and dental procedures—require or encourage you to check coverage before you incur the claim.
Mandatory Prior Approval
Certain specialty and high-cost prescriptions or devices require prior approval from GreenShield before your claim can be reimbursed. Additionally, these prescriptions may need to be purchased from an approved pharmacy that is part of GreenShield’s Specialty Drug Preferred Provider Network (PPN).
To determine if your prescription requires prior approval or is included in the PPN, you can use the online drug search tool available through GreenShield’s Plan Member Online Services. Alternatively, you can contact GreenShield’s Customer Service Centre for assistance.
How to Request Prior Approval
- Consult Your Healthcare Provider: Discuss the need for a specialty or high-cost prescription or medical device with your healthcare provider. They can help determine if prior approval is necessary.
- Submit the Request: If prior approval is required, your healthcare provider will need to submit a request to GreenShield on your behalf. This request will include relevant medical information to support the need for the prescription or medical device.
- Await Approval: Once the request is submitted, GreenShield will review it and notify you and your healthcare provider of the decision. If approved, you can proceed with your prescription or device purchase.
- Claim Submission: After obtaining the approved prescription or device, you can submit your claim for reimbursement according to the guidelines provided by GreenShield.
Understanding the prior approval process is essential for ensuring that you receive the prescriptions and medical devices you need without unnecessary delays.
Important Note:
The plan member is responsible for any costs your healthcare provider charges to fill out or sign your predetermination form, as this cost is not covered by the UA Local 67 Benefits Plan.
Voluntary Predetermination
Take the guesswork out of your healthcare decisions! Predetermination is an important step in managing your health and dental expenses under the UA Local 67 Benefits Plan. This process allows you to obtain approval for specific treatments or services before they are provided, ensuring that you understand your coverage and any potential out-of-pocket costs.
Even if your prescribed treatment, supply or device doesn’t require GreenShield’s prior approval, it’s still recommended to obtain a voluntary predetermination before making a costly purchase (including dental procedures over $300), to confirm coverage and avoid unexpected expenses.
Have Any Questions?
If you have any questions about prior approval or predetermination, or need assistance, contact GreenShield today or reach out to your UA Local 67 Benefits team.