Medica does not require prior authorization for certain services.
Please use the Enterprise Prior Authorization List (EPAL) to see what services do require authorization in the Prior Authorization and Plan Requirement Resources section > under Plan Requirements and Procedure Codes > Medica Healthcare and Preferred Care Partners Prior 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 inpatient admissions, including Skilled Nursing Facilities (SNF), 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 HomeHealth 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 a prior authorization be expedited by placing ‘STAT’ or ‘urgent’ on the Prior Authorization Form.
- Prior authorizations are required for referrals to out- ofnetwork 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 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 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.
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 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.
Facilities are responsible for admission notification for:
- Planned elective admissions for acute care
- Unplanned admissions for acute care
- Admissions following observation
- Admissions following outpatient surgery
- Skilled Nursing Facility (SNF) admissions
- Long Term Acute Care Hospital (LTACH)
- Acute Inpatient Rehab (AIR)
- Unless otherwise indicated, admission notification must be received within 24 hours after actual weekday admission (or by 5 p.m. Eastern 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 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 may not be billed.
A notification or prior authorization approval does not ensure or authorize payment, subject to state rules and Medicare Advantage policies. Payment depends on the member’s coverage, the care provider’s eligibility and Agreement and claim requirements.
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.
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 of the necessary documentation at the time of your request to help with the decision.
Certain services require prior authorization, which results in:
- A request for clinical information,
- A clinical coverage review based on medical necessity, and
- 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.
- We may also use tools developed by third parties, such as the MCG™ Care 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 Medicare Advantage 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 utilized in applying clinical 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 and medical technology assessment information
- CMS NCDs and LCDs, and other based clinical literature (for Medicare and Retirement)
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:
- 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.
For Inpatient Care Management Cases, peer-to-peer requests may come in through the Peer-to-Peer Support team by calling 800-955-7615.
Peer-to-peer discussions may occur at different points during case activity in accordance with timeframes, once a medical director has rendered an Adverse Determination. A peer-to-peer reconsideration request may only occur before you file a formal appeal.
UnitedHealthcare 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 peer-to-peer review. A clinician will contact you to initiate the peer-to-peer call. Please follow 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 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 our members, 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 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 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.