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Prior Authorizations and Referrals - Medica HealthCare Supplement, 2018 UnitedHealthcare Administrative Guide

Simple Referral Process

Medica HealthCare’s Simple Referral Process helps Primary Care Physicians coordinate patient care.

Referrals are needed for most participating specialists.* Requests for non-participating care providers need additional authorization.

  • You can request a referral for one or multiple visits.
  • The referral is good for the number of visits approved, valid for six months from the date issued.
  • No supporting documentation needed for referrals to specialists.
  • Submit all requests for referrals through our online provider portal on UHCprovider.com/priorauth.
  • Upon submitting a referral request, the system automatically generates the referral number.
  • For member convenience, you can also provide members with a copy of the referral confirmation.
  • Specialists have the ability to view referral via UnitedHealthcare portal.
  • For additional questions call us at 877-670-8432 or email us at pcp-NetworkManagementServices@uhcsouthflorida.com.

* Contact Network Management Services for a complete list of specialty types that need referrals.

Services Not Requiring Prior Authorization

Medica does not require prior authorization for certain services. Please use the Enterprise Prior Authorization List (EPAL) to see what services do require authorization on UHCprovider.com > Prior Authorizations and Notifications > Advance Notification and Plan > under Plan Requirement Resources > Medica Healthcare and Preferred Care Partners Prior Authorization Requirements.

Authorization Requirements

  • You are responsible for getting prior authorization for all services requiring authorization before the services are scheduled or rendered.
  • Submit prior authorization for outpatient services or planned hospital admissions, including Acute Inpatient Rehab (AIR) and Long Term Acute Care Hospital (LTACH) admissions, as far in advance of the planned service as possible to allow for review. You are required to submit prior authorizations at least seven calendar days prior to the planned date of service.
  • Prior authorizations for home health and home infusion services, durable medical equipment, and medical supply items should be submitted to MedCare Home Health is 305-883-2940 and Infusion/DME at 800-819-0751.

Note: Do not request an expedited (72 hours) review unless it is determined that 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 that a prior  authorization be expedited by placing ‘STAT’ or ‘urgent’ on the Prior Authorization Form.

  • Prior authorizations are required for referrals to out-of-network care providers when the member requires a necessary service that is not within the Medica network. The referring physician must submit a completed Prior Authorization Form for approval.
  • It is important that you and the member are fully aware of coverage decisions before you render services.
  • If you provide the service before a coverage decision is rendered, and we determine that the service was not a covered benefit, we may deny the claim and you must not bill the member. Without a coverage determination, a member does not have the information needed to make an informed decision about receiving and paying for services.

Notification Requirements

Prior to doing an inpatient or ambulatory outpatient service requiring prior authorization, the facility must confirm that 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 inpatient services even if the coverage approval is on file.
  • If a member is admitted through the emergency room, notification is required no later than 24 hours from the time the member is admitted for purposes of concurrent review and follow-up care.
  • If a member receives urgent care services, you must notify us within 48 hours of the services being rendered.

Admission Notification Requirements

Facilities are responsible for admission notification for the following types of inpatient admissions:

  • Planned elective admissions for acute care
  • Unplanned admissions for acute care
  • Skilled Nursing Facility (SNF) admissions
    • Notify us of admissions to SNF within 24 hours. Prior authorizations are not required.
  • Admissions following outpatient surgery
    • Long Term Acute Care Hospital (LTACH) and Acute Inpatient Rehab (AIR) require prior authorization.
  • Admissions following observation
  • Acute inpatient rehabilitation admission
  • LTACH admissions
  • Unless otherwise indicated, admission notification must be received within 24 hours after actual weekday admission (or by five p.m. local time on the next business day if 24 hour notification would require notification on a weekend or federal holiday). For after-hour, weekend and federal holiday admissions, please call the Utilization Management Department at 866-273-9444 for assistance.
  • Even if the physician gave us the admission notification, the facility still needs to submit one as well.
  • Receipt of an admission notification does not guarantee or authorize payment. Payment of covered services depends on:
    • The member’s coverage
    • The facility being eligible for payment
    • Claim processing requirements
    • The facility’s participation agreement with us
  • Admission notifications must contain the following:
    • Member name and member health care ID number
    • Facility name
    • Admitting/attending physician name
    • Description for admitting diagnosis or ICD-10-CM (or its successor) diagnosis code
    • Actual admission date
    • Admission orders written by a physician
  • For emergency admissions when a member is unstable and not capable of providing coverage information, the facility should notify us as soon as the information is known and communicate the extenuating circumstances. We will not apply any notification- related reimbursement deductions.

If the requirements described are not followed, the services may be denied. The member cannot 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 participation agreement and claim requirements.

How to Request Prior Authorization

  • Online: UHCprovider.com/priorauth.
  • Phone: If you do not have electronic access, call the number on the back of the members’ health care ID card.
  • Fax: For manual prior authorizations, the requesting care provider must complete and sign the Prior Authorization Form, and fax it to 855-307-8531.

Required Information for Prior Authorization Prior Authorizations Must Have:

  • Member information: Name, date of birth (DOB), and membership ID number
  • Requesting care provider information: Name, specialty, designate par or non-par, address and phone and fax numbers
  • Primary care physician information, if different from the requesting care provider: Name, phone and fax numbers
  • Referral information: Name of referral care provider, designate par or non-par, address, phone and fax numbers
  • Diagnosis or symptoms: Include the diagnosis description and the corresponding ICD-10 code for each diagnosis to the highest specificity
  • Service(s) Requested:
    • Identify each procedure, and its corresponding CPT code,
    • Document any pertinent clinical summary information which would be helpful to that specialist or for the UM determination in the additional comments field, and
    • Enter the date of service and number of visits requested, and sign where indicated.

Where a clinical coverage review is required in the member’s benefit plan, we may request additional information.

  • We may not cover certain services within an individual member’s benefit plan, regardless of whether prior authorization is required.
  • In the event of a conflict or inconsistency between applicable regulations and the Advance Notification Requirements in this manual, we follow the notification process in accordance with applicable regulations.

Timeframes for Processing Prior Authorization Requests

We will make a determination within 14 calendar days of receipt, or within 72 hours for an expedited review.

It is important that we have all of the necessary documentation at the time of your request to help with the decision.

Clinical Coverage Review

Certain services require prior authorization, which results in:

  1. A request for clinical information,
  2. A clinical coverage review based on medical necessity, and
  3. A coverage determination.

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 provider, you must return calls from our UM staff or Medical Director. You must provide complete clinical information as required within the timeframe specified on the outreach form.

In addition:

  • We may also use tools developed by third parties, such as the MCG™ guidelines, to assist us in administering health benefits and to assist clinicians in making informed decisions in many health care settings. These tools are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.
  • For MA members, we use CMS coverage determinations, the National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) to determine clinical criteria for Medicare members. There is a hierarchy that is utilized in applying clinical criteria.

Clinical Coverage Review Criteria

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) utilize evidence based MCG Care Guidelines.

Clinical coverage decisions are based on:

  • The member’s eligibility
  • State and federal mandates
  • The member’s certificate of coverage, evidence of coverage or summary plan description
  • UnitedHealthcare medical policies, medical technology assessment information
  • CMS NCDs and LCDs, and other based clinical literature (for Medicare and Retirement)

Coverage Determination Decisions

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 that the individual will support or tend to support the denial of benefits.

Prior Authorization Denials

We may deny a prior authorization request for several reasons:

  • Member is not eligible;
  • Service requested is not a covered benefit;
  • Member’s benefit has been exhausted; or
  • Service requested is identified as not medically necessary (based upon clinical criteria guidelines).

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.

Peer-to-Peer (P2P) Clinical Review

For Inpatient Care Management Cases, P2P requests may come in through the P2P Support team by calling 800-955- 7615.

P2P discussions can occur at different points during case activity in accordance with timeframes, once a medical director has rendered an Adverse Determination. A P2P reconsideration request can only occur before you file a formal appeal.

Medica physicians conducting clinical review determinations are available, by telephone, 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. Please follow time line provided by the nurse during the call.

Additional UM Information

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 at 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 healthcare 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 your patients, please contact Utilization Management at 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

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:

  • An extension of the approval is needed. Contact must be made prior to the expiration of the approved days. 
  • The member’s discharge plan indicates that transfer to an alternative level of care is appropriate.
  • The member has a complex plan of treatment that includes home health services, home infusion therapy, total parenteral nutrition, or multiple or specialized durable medical equipment identified prior to discharge. 
  • Addressing lifestyle-related health issues and referring to programs for weight management, nutrition, smoking cessation, exercise, diabetes education and stress management, as appropriate. 
  • Helping members understand and manage their condition and its implications. 
  • Education for reducing risk factors, maintaining a healthy lifestyle, and adhering to treatment plans and medication regimens.