Medica does not require prior authorization for certain services. Use the Enterprise Prior Authorization List (EPAL) to see what services do require authorization on UHCprovider.com/priorauth> Plan Requirements for Advance Notification/Prior Authorization > under Plan Requirements and Procedure Codes > Medica HealthCare and Preferred Care Partners Prior Authorization Requirements.
Note: Request an expedited (72 hours) review if waiting for a standard (14 calendar days) review could place the member’s life, health, or ability to regain maximum function in serious jeopardy. If the situation meets this definition, request a prior authorization be expedited by placing ‘STAT’ or ‘urgent’ on the Prior Authorization Form.
Prior to doing an inpatient or ambulatory outpatient service requiring prior authorization, the facility must confirm the coverage approval is on file. This promotes conversations between the facility and the member about the cost for the procedure.
Facilities are responsible for admission notification for the following inpatient admissions, even if advance notification was provided by the physician and coverage approval is on file:
If the requirements described are not followed, the services may be denied. The member may not be billed.
A notification or prior authorization approval does not ensure or authorize payment, subject to state rules and MA policies. Payment depends on the member’s coverage, the care provider’s eligibility and Agreement and claim requirements.
Where a clinical coverage review is required in the member’s benefit plan, we may request additional information.
We will make a determination within 14 calendar days of receipt, or within 72 hours for an expedited review. It is important we have all necessary documentation at the time of your request to help with the decision.
Certain services require prior authorization, which results in:
You must cooperate with our requests for information, documents or discussions for purposes of a clinical coverage review including, providing pertinent medical records, imaging studies and reports and appropriate assessments for determining degree of pain or functional impairment.
As a network care provider, you must return calls from our UM staff or Medical Director. You must provide complete clinical information as required within the time frame specified on the outreach form.
We use scientifically based clinical evidence to identify safe and effective health services for members for inpatient and outpatient services. For inpatient care management (ICM’s), we use evidence-based MCG Care Guidelines. Clinical coverage decisions are based on:
We base coverage determinations for health care services upon the member’s benefit documents and applicable federal requirements. Our UM staff, its delegates, and the physicians making these coverage decisions are not compensated or otherwise rewarded for issuing adverse non-coverage determinations.
Medica HealthCare and its delegates do not offer incentives to physicians to encourage underutilization of services or to encourage barriers to receiving the care and services needed.
Coverage decisions are made based on the definition of “reasonable and necessary” within Medicare coverage regulations and guidelines. We do not hire, promote or terminate physicians or other individuals based upon the likelihood or the perceived likelihood the individual will support or tend to support the denial of benefits.
We may deny a prior authorization request for several reasons:
We must notify you and the member in writing of any adverse decision (partial or complete) within applicable time frames. The notice must state the specific reasons for the decision, and reference to the benefit provision and clinical review criteria used in the decision making process. We provide the clinical criteria used in the review process for making a coverage determination along with the notification of denial.
For ICM, P2P requests may come in through the P2P support team by calling 1-800-955-7615.
P2P discussions may occur at different points during case activity in accordance with time frames, once a medical director has rendered an adverse determination. A P2P reconsideration request may only occur before you file a formal appeal.
UnitedHealthcare physicians conducting clinical review determinations are available by phone, to discuss medical necessity review determinations with the member’s physician requesting the service. We offer pre-denial P2P review. A clinician will contact you to initiate the P2P call. Follow the time line provided by the nurse during the call.
External agency services for members
Some members may require medical, psychological, social services or other external agencies outside the scope of their benefits (for example, from Health and Human Services or Social Services). If you encounter a member in this situation, you should either contact Network Management Services, or have the member contact our Member Services department at1-800-407-9069 for assistance with, and referral to, appropriate external agencies.
Technology assessment coverage determination
We use the technology assessment process to evaluate new technologies and new applications of existing technologies. Technology categories include medical procedures, drugs, pharmaceuticals, or devices. This information allows us to support decisions about treatments which best improve member’s health outcomes, efficiently manage utilization of health care resources, and make changes in benefit coverage to keep pace with technology changes and to help ensure members have equitable access to safe and effective care. If you have any questions regarding whether a new technology or a new application of existing technologies are a covered benefit for our members, contact UM at 1-866-273-9444.
Hospitalist program for inpatient hospital admissions
The Hospitalist Program is a voluntary program for members. Hospitalists are physicians who specialize in the care of members in an acute inpatient setting (acute care hospitals and skilled nursing facilities). A hospitalist oversees the member’s inpatient admission and coordinates all inpatient care. The hospitalist is required to communicate with the member’s selected physician by providing records and information such as the discharge summary, upon the member’s discharge from the hospital or facility.
Discharge planning is a collaborative effort between the inpatient care managers, the hospital/facility case manager, the member, and the admitting physician to ensure coordination and quality of medical services through the post-discharge phase of care.
Although not required to do so, we may assist in identifying health care resources, which may be available in the member’s community following an inpatient stay.
Utilization case management nurses conduct telephone reviews to support discharge planning, with a focus on coordinating health care services prior to the discharge.
The facility or physician is required to contact us and provide clinical information to support discharge decisions under the following circumstances: