Preauthorization Guidelines

DMBA General Preauthorization Guidelines

Preauthorization (sometimes referred to as pre-certification or prior approval) is a process we use to confirm whether a proposed service or procedure is medically necessary. It helps minimize your share of the costs for services you receive. Generally, the plans offered by DMBA are preferred provider organizations or PPOs, meaning your benefits are higher when you receive care from contracted providers (physicians, hospitals, etc.). Click here to find DMBA contracted providers.

Note: Deseret Alliance participants are subject to Medicare guidelines; preauthorization is not required

It is important to know if your provider has obtained preauthorization, particularly when visiting an out-of-network provider who may not be familiar with DMBA’s policies and requirements.

To preauthorize, you or your physician must call DMBA at least two business days before your anticipated services. In an emergency situation when you or your physician cannot contact DMBA beforehand, you or your physician must call DMBA within two business days after the emergency or as soon as reasonably possible.

Contact DMBA to confirm whether preauthorization is required before services are rendered or to determine whether a proposed test, equipment, service, or procedure requires preauthorization.

Click here to access DMBA’s preauthorization request form.

Requires preauthorization (not an all-inclusive list)

  • Air transport (non-emergent)
  • Ambulance transportation (preauthorization recommended)
  • Applied behavior analysis (ABA) therapy for Autism Spectrum Disorder (The initial assessment does not require preauthorization.)
  • Artificial intervertebral discs
  • Auditory brain stem implant
  • Bariatric surgery/obesity surgery (inpatient and outpatient)
  • Biofeedback
  • Bone anchored hearing aid (BAHA)
  • Bone morphogenic protein (BMP) grafting
  • Botox (botulinum toxin) for any indication
  • Brachytherapy
  • Cosmetic in nature (not an all-inclusive list):
    • Breast surgeries (e.g., reduction mammoplasty, gynecomastia excision, etc.)
    • Nasal surgeries (e.g., rhinoplasties, septorhinoplasties, etc.)
    • Congenital defects (e.g., a missing ear, extra finger, or some facial disfigurements)
    • Ear surgery (e.g., otoplasty, to correct certain defects or deformities)
    • Eyelid surgery (e.g., blepharoplasty)
    • Jaw surgery (maxillary and mandibular osteotomies)
    • Scar revisions
    • Varicose veins
  • Breast reconstructive surgery after breast cancer
  • Cochlear implant
  • Durable medical equipment (DME) such as (not an all-inclusive list):
    • Airway clearance devices
    • Apnea monitors
    • BI-PAP machines
    • Bone growth stimulators
    • Breast pumps (hospital grade)
    • Cardiac defibrillator vest
    • Communication devices
    • Continuous glucose monitoring system
    • Continuous passive motion devices (for home use)
    • C-PAP machines
    • Gait trainers
    • Hospital beds
    • Insulin pumps
    • Lift systems (Hoyer, etc.)
    • Lymphedema pumps
    • Oxygen
    • Oximeters (continued use) (Overnight oximeters do not require preauthorization)
    • Pain pumps
    • Prosthetics
    • Respirators/ventilators
    • Sacral nerve stimulator for urinary voiding dysfunction
    • Seasonal Affective Disorder (SAD) lights
    • Spinal cord stimulators for treatment of pain
    • Wheelchairs/Scooters
  • Enteral formula (Pump and supplies do not require preauthorization.)
  • Fetoscopic laser ablation
  • Genetic testing
  • Hip resurfacing (partial/total)
  • Home health nursing
  • Home intravenous infusion therapy (Medication and nursing visits require preauthorization. Pump and supplies do not require preauthorization.)
  • Hormonal therapy
  • Hospitalizations
    • Inpatient admissions
    • Long-term acute care (LTAC)
    • Maternity extended stay (more than two days for vaginal delivery, or more than four days for cesarean delivery)
    • Rehabilitation (inpatient rehab)
    • Skilled nursing facility (SNF)
  • Hospice
  • Hyperbaric oxygen therapy
  • Intrastromal corneal ring segment (ICRS)
  • In vitro fertilization
  • Medications: Certain medications require preauthorization when administered in a physician’s office, an infusion center, or at home with skilled nursing. If you have questions about a specific medication, please contact DMBA Member Services.
  • Mental Health (not an all-inclusive list):
    • Alternative care (residential, partial hospitalization, intensive outpatient)
    • Chemical dependency/substance abuse
    • ECT Therapy
    • Inpatient hospital services
    • Neuropsychological testing
    • Psychological testing
  • Mirena IUD
  • Ocular amniotic membrane transplant
  • Oral appliances
  • Percutaneous tibial neurostimulation
  • Radiology (not an all-inclusive list):
    • Brachytherapy
    • Magnetoencephalography (MEG)
    • PET/PET-CT scans
    • Proton beam therapy
  • Speech therapy (outpatient)
  • Stereotactic radiosurgery
  • Sterilization procedures
  • Transplants (not an all-inclusive list):
    • Bone marrow
    • Heart
    • Intestine
    • Kidney
    • Liver
    • Lung
    • Pancreas/kidney
    • Heart/lung
  • Ventricular assist devices (BIVAD, LVAD, RVAD)
  • Wearable cardioverter defibrillator
Providers and participants are encouraged to call for verification of coverage for procedures that may be considered:
  • New/emerging technology
  • Experimental technology
  • Exclusions to the plan
  • Clinical trials
All procedures, services, therapies, devices, etc., must be covered by the plan and meet our medical criteria to be eligible for benefits. If your situation isn’t covered by the plan or doesn’t meet our medical guidelines and DMBA ultimately denies benefits for the service, you are responsible for all charges.

BYU, LDS Business College, BYU-Idaho, and BYU-Hawaii

You and your covered dependents must use the Student Health Center (SHC) as your primary care provider. Any service provided outside the SHC requires a referral from the SHC and preauthorization from DMBA. If you receive services at the SHC of another Church university, you will be covered at 100% for eligible services. You must pay the SHC copayment at the time of service. You don’t need preauthorization.

Referrals: If you or your covered dependents need to see a specialist outside the SHC, you must obtain a referral from the SHC before making an appointment with the specialist.

Preauthorization: For services received outside of the health centers to be eligible for maximum benefits, you must preauthorize them before you receive the medical care. If you don’t preauthorize, you may be responsible for an additional $100 copayment for each service.

To preauthorize outpatient services:

  • In Utah, call the SHC authorization line at 801-422-2771 (choose option 5). To preauthorize all other services (inpatient hospital in Utah or all services outside of Utah), call DMBA at 800-777-3622.
  • In Idaho, call DMBA at 800-777-3622 before you receive the medical care.
  • In Hawaii, call DMBA at 808-675-3972.
  • Outside of the United States, you must preauthorize services by calling DMBA at 800-777-3622 or by faxing information to 801-578-5916.
Providers: Please click here to find and review the handbook for the plan covering your patient.