Frequently Asked Questions (FAQs)

• My Pre-Notification needs a pre-existing review. What are pre-existing conditions?

  Per program guidelines, Pre-Existing Condition means: (1) any sickness or injury for which a Member, within 24 months before the Member’s Active Date, received medical treatment, advice, care, or services (including diagnostic measures), took prescribed drugs, or showed signs and symptoms (whether treated or not), or (2) any chronic, persistent, or long-lasting medical condition which is unresolved and known to the Member, regardless of whether, within 24 months before the Member’s Active Date, the condition required treatment, advice, care, services, or prescription drugs, or exhibited any signs or symptoms. Eligibility for a Pre-Existing Condition, or for any medical condition caused by or directly related to a Pre-Existing Condition, has a 24-month Waiting Period.

• My Pre-Notification was denied, how can I appeal this decision?

  If you do not agree with the determination made during the prenotification review, you may submit a written appeal by clicking on the link. https://www.onesharehealth.com/member-disputes

• How long does a prenotification take?

  There are three options when submitting a prenotification request: Standard (10-14 business days), Quick Response (7-10 business days), and Expedited (1-10 business days) after all necessary information has been collected. I.E. Medical record release forms, medical records from all providers or facilities needed for Clinical Review to determine eligibility.

• Do scans require Pre-Notification?

  Not all scans require a Pre-Note. Here is a list of “Non-Invasive” tests that do not require a Pre-Note:

  • Xray

  • MRI/MRA

  • CT/CAT/CTA scan

  • Echocardiogram

  • Nuclear Stress Test

  • Ultrasound/Doppler

  • EKG

  • Mammogram/Diagnostic Mammogram

  • Bone Density/DEXA scan

  • HIDA scan

  • Pulmonary Function Tests (PFTs)

  • Allergy Injections

• Does a Screening Colonoscopy require Pre-Notification?

  Screening Colonoscopies don’t require a Pre-Notification unless partnered with a Biopsy.  

  *The recommended age for a screening colonoscopy is 45 or older. Under 45 if the member has a family history.*