Our Utilization Management (UM) Program has several parts. These include but are not limited to:
- Preauthorization for various procedures, medical services, treatments, prescription drugs and durable medical equipment (DME).
- Review of the appropriateness of inpatient admissions and ongoing inpatient care coverage.
- Prior approval for referrals to non-participating care providers, if applicable.
- Case management.
Did You Know?
The term “prior authorization” is also referred to as “Preauthorization.”
Our goal is to encourage the highest quality of care in the right place at the right time from the right care provider.
Care providers must cooperate with our UM program. You will allow us access, in the form we request, to data about covered services provided to our members. You will allow us to collect data to conduct UM reviews and decisions.
Medical Policies, Drug Policies and Coverage Determination Guidelines
River Valley uses UnitedHealthcare’s Medical Policies, Drug Policies, Coverage Determination Guidelines, Quality of Care Guidelines, and Utilization Review Guidelines on Medical & Drug Policies and Coverage Determination Guidelines.
Services that Require Preauthorization
We require preauthorization for certain procedures, DME, prescription drugs and other services.
Submit Adequate Clinical Documentation
You must request preauthorization when required. Provide complete clinical information and supporting medical documentation for each procedure, device, drug or service when you submit your request. That way, we can promptly determine whether the services are covered and medically necessary.
The list of services requiring preauthorization is available on Advance Notification and Plan Requirement Resources, under UnitedHealthcare of the River Valley Advance Notification Procedure Codes.
We consider additional information provided within the time period allowed for review. However, delayed submissions increase administrative time.
Refer to our Medical Policies, Drug Policies and Coverage Determination Guidelines for what information to provide.
How to Request Preauthorization
Refer to How to Contact River Valley in this supplement for how to submit a request for preauthorization.
If you do not get a required preauthorization, the claim may be denied. You cannot bill the member for denied services.
Preauthorization Review Hours of Operation
Staff can review your preauthorization requests Monday through Friday from 8 a.m. until 4:30 p.m. Central Time.
Medical Directors are available to discuss clinical policies or decisions by calling 877-842-3210. The office is closed for national holidays and the day after Thanksgiving.
Clinical Review of a Preauthorization Request
When we receive a preauthorization request, our Clinical Coverage Review Department evaluates the information to determine whether the procedures, devices, drugs or other services are medically necessary and appropriate. Our nursing staff makes decisions to approve care based on specific criteria.
Care and/or services that do not fall within the criteria are referred to a medical director or other appropriate reviewer. This may include a board-certified specialty physician or a registered pharmacist. Only physicians and other appropriate care providers may issue a medical necessity denial.
River Valley’s staff and our delegates who make these decisions are not rewarded for denying coverage. We do not offer incentives that encourage underutilization of care or services.
The treating physician has the ultimate authority for the member’s medical care. The medical management process does not override this responsibility.
Utilization Management Decisions
We make Utilization Management decisions within the time frames set by state and federal law (including ERISA). We make UM decisions in accordance with National Committee for Quality Assurance (NCQA) standards.
We also tell care providers and members our decisions according to applicable state and federal law as well as to NCQA standards and River Valley policy. Denial letters explain members’ applicable appeal rights, which may include the right to an expedited and/or external review. They also explain the requirements for submitting an appeal and receiving a response.
A member may have a health care professional appeal a decision on their behalf. We require a copy of the member’s written consent with the appeal.
Facility Utilization Review
Facilities must notify us of an inpatient admission within 24 hours of admission or on the next business day after a holiday or weekend.
We need the member’s name, ID number, admitting diagnosis and attending physician’s name.
If the facility does not tell us about an admission as required, claims will be returned as not allowed.
The facility may not bill the member for the services.
Retrospective reviews may be completed, and any approved services may be re-billed.
Our UM activities include inpatient review. We usually begin our review on the first business day following admission. The medical director and clinical staff review member hospitalizations for over- and under-utilization. Then they decide whether the admission and continued stay are medically appropriate and align with evidence-based guidelines.
Where appropriate, River Valley also uses MCGTM Care Guidelines. These are nationally recognized clinical guidelines that help clinicians make informed decisions, on a case-by-case basis, in many health care settings. These settings include acute and sub-acute medical, rehabilitation, skilled nursing facilities (SNF), home health care and ambulatory facilities. Other criteria may be used when published peer-reviewed literature or guidelines are available from national specialty organizations that address the admission or continued stay.
When the guidelines are not met, the medical director considers community resources and the availability of alternative care settings. These include skilled facilities, sub-acute facilities or home care, and the ability of the facilities to provide all necessary services within the estimated length of stay.
Inpatient review also helps us contribute to decisions about discharge planning and case management. In addition, we may identify opportunities for quality improvement and cases appropriate for referral to one of our disease management programs.
If a nurse reviewer believes an admission or continued stay does not meet criteria, you may be asked for more information about the treatment and case management plan. The nurse then refers the case to our medical director. If the medical director determines an admission or continued stay at the facility, being managed by a participating physician, is not medically necessary, we tell the facility and the care provider.
You may speak with our medical director within one business day of the request. When decisions require expertise outside the scope of the physician advisor, we have a board-certified physician of the relevant specialty (or similar specialty) review the case. We use external independent review when we decide it is appropriate or by member request, according to applicable law.
We require prior authorization for admission for all rehabilitation confinements. We review them concurrently for continued services.
Refer to the Skilled/Extended Care in the How to Contact River Valley section in this supplement for how to submit a preauthorization request.
A member may require inpatient skilled nursing care due to acute illness, injury, surgery, or exacerbation of a disease process.
- We require notification for all admissions to a SNF (or skilled level of care within an acute facility). Refer to How to Contact River Valley in this supplement for how to submit a notification request.
- The facility must submit the care plan along with treatment goals, summary of services to be provided, expected length of stay (LOS), and discharge plan.
- We authorize admission consistent with the level of care required based on the treatment plan.
- The skilled facility provider must provide appropriate documentation, including changes in the level of care.
- Approval for additional days of authorized coverage must be obtained before the authorization expires.
- Decisions about levels of care must consider not only the level of service but the member’s medical stability.
- Our medical director will speak with the physician managing the member in the skilled facility about disagreements concerning the level of care required. The member or authorized representative can request an appeal when coverage is not approved. We determine whether the admission, stay and care are covered and medically necessary based on the following clinical guidelines, among others:
- Physicians must order services. The services must be necessary for treatment. They must align with the nature and severity of the illness or injury, medical needs, and accepted medical practice standards. The member must be stable. Clinical and lab findings must have either improved or not changed for the last 24 hours. Diagnosis and initial treatment plan must be established before admission. The services must be reasonable in terms of duration and quantity. The member must require daily (i.e., available on a 24-hour basis, seven days/week) skilled services. If skilled rehabilitation services are not available on this basis, a member whose stay is based on the need for them would meet the daily basis requirement when they need and receive those services at least five days a week. Skilled services, however, are required and provided at least three times per day. How often a service must be performed does not make it a skilled service.
- We consider the nature and complexity of a service and the skills required for safe and effective delivery when determining whether a service is skilled. Skilled care requires trained medical personnel to frequently review the treatment plan for a limited time. It ends when a condition is stabilized or a predetermined treatment plan is completed. Skilled care moves the member to functional independence.
Observation helps care providers determine whether a member needs to be admitted to a hospital. It may be needed to monitor or diagnose a condition when testing or treatment exceeds usual outpatient care.
Observation is used when physicians need 48 hours or less to determine a member’s condition. In some cases, more than 48 hours may be necessary.
Members may be admitted when a condition is diagnosed requiring a long-term stay (e.g., acute MI). This condition may involve long-term treatment or further monitoring (e.g., persistent severe asthma).
Notice of Termination of Inpatient Benefits
We may determine that an admission, continued hospital stay, rehabilitation unit or SNF are not covered. These reasons include but are not limited to:
- A medical director determines an admission or continued stay, which was not preapproved at an out-of-network (OON) facility, is not medically necessary at the facility’s level of care.
- Preauthorization was not obtained for a procedure or service that needed it.
- A medical director determines the member’s condition is custodial and is not covered.
- A medical director, upon consulting with the attending physician, determines continued acute inpatient rehabilitation/SNF level of care is no longer medically necessary, but the patient refuses discharge.
- The member has used all inpatient or skilled care benefits under their benefit plan. If a non-coverage determination is made, we provide written notification to the physician, the member and facility that day.
Services Obtained Outside the River Valley Service Area
- We process treatment authorizations as directed by you and the out-of-area (OOA) attending physician.
- With you and the OOA attending physician, we coordinate a member’s transfer back to the service area when medically feasible and appropriate.
- We cover OOA urgent or emergent stabilization services according to the member’s benefit plan. This includes the time they are stabilized in the emergency room before admission as an inpatient and are discharged.
- We cover post-stabilization care services.
- We cover OOA inpatient services until the member is stable enough to be transferred to a participating hospital. Transfers should happen within 48 hours of that point. Payment for preventive or non-emergent/ urgent services performed outside the network varies by benefit plan. Determinations on benefit coverage may include but are not limited to non-covered, covered at a lower benefit level, or covered at the network level with a referral. Call Member Services for questions.
Special Requirements Durable Medical Equipment (DME)
Preauthorization is required for some DME. Refer to the How to Contact River Valley section of this supplement for how to submit a preauthorization request.
Subject to the noted exceptions, members must get all DME, orthotics, prosthetics and supply items from a contracted vendor. If an item is not available from a contracted vendor, whether or not preauthorization is required, you must get an OON referral. Otherwise, payment will be denied unless the member has an OON DME benefit.
Note: Even when medically necessary, certain items (e.g., orthotic devices) may not be covered. Others (e.g., prosthetic devices) may be subject to benefits limits. Contact Member Services for information about a member’s plan and preauthorization requirements.
We require preauthorization for some prescription drugs. Refer to the How to Contact River Valley section of this supplement for how to submit a preauthorization request.
Some drugs have special rules and require special management services. These include drugs with therapy prerequisites, quantity limitations and/or a multiple copays. A list of some drugs with such rules is on our Pharmacy section.
- If you order and/or administer any medication that requires preauthorization or clinical management services, you may need to get those medications from a participating specialty pharmacy unless we authorize a non-specialty pharmacy.
- Certain drugs are available in quantities up to 90- or 100-day supplies, depending on plan benefit design. A list of drugs on the three-month supply list is on our Pharmacy section.
- River Valley’s Prescription Drug Lists (PDL) is on our Pharmacy section.
Not all drugs on a Preferred Drug List are covered under the pharmacy benefit.
Sleep Studies to Diagnose Sleep Apnea and Other Sleep Disorders
We require preauthorization for laboratory-assisted and polysomnography treatment. We also require it for the site of service (e.g., sleep lab v. portable home monitoring).
Home Health Care (Including Home Infusion Services)
- We require preauthorization for home health care. This may include home infusion services.
- If requested services are required after business hours, notify us within 24 hours or the next business day following a holiday or weekend. Include the member’s name, ID number, diagnosis, the attending physician’s name and requested services.
- If you do not notify us, we will deny your claim. You may not bill the member for the service.
Assisted Reproduction Program
Most River Valley benefit plans exclude coverage for infertility evaluation or treatment. Some employer groups have a variation or rider to cover these services. Some states, however, require fertility treatment coverage for some groups. Refer to How to Contact River Valley section of this supplement for pre-authorization contact information.
- We require preauthorization for transplants. Call the Optum transplant case manager at 888-936-7246. They will request medical records to see whether the transplant is appropriate for a member. We send all information to a physician expert in the related transplantation field for review.
- If authorized, the case manager coordinates referrals and helps select a transplant center based on the member’s needs. They also provide information about our transplant management program.
- If a transplant candidate needs home care or is involved with a participating center, the transplant care manager will arrange service.
- Any post-transplant lab or pathology that cannot be performed or interpreted by a network physician can be sent to the transplant center for interpretation. Tell the transplant case manager if you need help making arrangements. Most of these services are covered under the transplant contract. The transplant center should be involved in the member’s continuing care.
- We require preauthorization for all follow-up care. Make requests using the standard River Valley preauthorization process.
- One year after the transplant, members are transferred to their local physician for any other needed care management services.
Some members have end-of-life care benefits, which may include hospice services. These services require preauthorization. Approved care is coordinated by our care managers.