Our Utilization Management (UM) Program has several parts. These include but are not limited to:
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.
River Valley uses UnitedHealthcare’s Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines, Quality of Care Guidelines, and Utilization Review Guidelines on UHCprovider.com/policies > Commercial Policies > Medical & Drug Policies and Coverage Determination Guidelines for UnitedHealthcare Commercial Plans.
For more information refer to Medical & Drug Policies and Coverage Determination Guidelines for Commercial Members in Chapter 6: Medical Management.
We require preauthorization for certain procedures, DME, prescription drugs and other services.
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 may promptly determine whether the services are covered and medically necessary. We consider additional information provided within the time period allowed for review. However, delayed submissions increase administrative time.
Refer to our Medical & Drug Policies and Coverage Determination Guidelines for what information to provide.
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.
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 may not bill the member for denied services.
Staff may review your preauthorization requests Monday through Friday from 8 a.m. until 4:30 p.m. CT. 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.
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.
We make UM 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.
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.
Facilities are responsible for admission notification even if advance notification was provided by the physician and coverage approval is on file.
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 row 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.
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).
We may determine that an admission, continued hospital stay, rehabilitation unit or SNF are not covered. These reasons include but are not limited to:
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 UHCprovider.com/pharmacy.
Not all drugs on a PDL are covered under the pharmacy benefit.
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).
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.
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.