Preauthorization Program, Concurrent Review, and Discharge Planning
Our authorization procedures involve the evaluation of requests for services prior to the delivery of care. When conducting preauthorization activities, network providers work with specially trained clinicians to ensure that the coordination and provision of medically necessary health care services occurs in a timely and efficient manner. To ensure that pre-authorization/pre-certification activities are conducted in a consistent manner and based on accepted clinical practice, our clinicians use standardized criteria to make medical necessity and appropriateness of level of care and determinations.
Inpatient admissions and selected outpatient services and procedures require pre-authorization/pre-certification. Selected outpatient services require submission of a treatment plan to evaluate medical necessity and appropriateness. The list of these services are reviewed periodically and distributed to providers and members and can be found in the provider manual. An initial length of stay will be provided with an inpatient authorization. Outpatient authorizations include the number of services to be provided. If additional information about a patient's status is required, the nurse reviewer will discuss the case with the attending physician and other members of the health care team.
Utilization Management staff is available to answer provider questions related to the utilization management process during normal business hours (8:00 AM to 6:00 PM Monday through Friday). Voicemails may be left after hours for return phone calls the next business day.
The criteria used in making a utilization management decision are available upon request by calling 800.471.2242.
Concurrent Review is conducted to evaluate and monitor the medical necessity and appropriateness of ongoing care and services. Concurrent review is performed by registered nurses using standardized clinical criteria. Concurrent review is provided on-site at a number of participating hospitals and facilities for inpatient admissions. If an on-site review is not performed during an inpatient confinement, telephonic reviews with the Facility's Utilization Review/Quality Improvement Department will be conducted.
Concurrent review is initiated for all inpatient admissions to an acute care hospital, skilled nursing facility, or rehabilitation hospital, and all services that require submission of a treatment plan and selected ongoing outpatient services.
Concurrent review will be conducted within 24 hours of an admission or the next business day following and admission or the receipt of a treatment plan. A registered nurse will review the member's medical record or treatment plan to evaluate the continued medical necessity and appropriateness of treatment and the patient's response to treatment. Subsequent reviews will be performed periodically to evaluate the medical necessity and appropriateness of continuing hospitalization and/or ongoing outpatient services.
Discharge planning is performed as necessary for inpatient confinements and selected ongoing outpatient services. Clinical management staff will coordinate the member's discharge from a facility, arrange for alternative services and discuss treatment options with the patient and patient's physician as appropriate.
Services Requiring Preauthorization
A member's coverage may require pre-authorization. Please check the member's identification card for this requirement.