Welcome to Your Prior Authorization Resource Center

As part of new requirements from the Centers for Medicare & Medicaid Services (CMS), ElderServe Health is committed to giving you clear, easy‑to‑understand information about:

Which services require prior authorization (PA)

Our yearly Prior Authorization Metrics, starting with Calendar Year (CY) 2025

Interoperability Prior Authorization Metrics

These requirements ensure our members have better visibility into how we use prior authorization and how these decisions may affect access to care.

Some services and treatments require Prior Authorization (PA) before they can be provided. This process helps ensure that the care you receive is medically necessary, safe, and covered under your plan benefits. Below is an easy‑to‑follow overview of how the PA process works so you know what to expect.

1. Your provider identifies a service that requires approval

Before moving forward with certain tests, procedures, equipment, or medications, your doctor or healthcare provider will check to see whether prior authorization is required based on your plan rules.

2. Your provider submits the request

If authorization is needed, your provider—not you—will submit a request to the plan.

3. We review the request using Medicare and clinical coverage guidelinesA clinical review is performed by trained nurses, pharmacists, or physicians to confirm the request meets medical necessity and Medicare coverage standards.

4. We notify you and your provider of the decision

Once a determination is made, both you and your provider will be informed.

Services That Require Prior Authorization

A complete and detailed list of all items and services requiring prior authorization is available here:

ElderServe Health Plans Service Requiring Authorization List

ElderServe Health Dental Service Requiring Authorization List