Prior authorization and utilization review
ROUTINE PRIOR AUTHORIZATION REVIEWS
When you submit a prior authorization request, Review Services will either approve or deny the request. If denied, you can appeal on your patient’s behalf.
First-level reviews:
Clinical specialists review the request based on clinical criteria and medical records. Supporting documentation must be submitted with the request. If the initial reviewer cannot approve it, the request is forwarded to a physician, pharmacist, or psychiatrist.
Second-level reviews:
If the first-level review results in a denial, a second-level reviewer may consult with the referring practitioner. If the second-level review is denied, a written notice of noncoverage will be mailed to the member and to the provider.
Notice or noncoverage:
This notice includes the denial rationale, review criteria, appeal instructions, and contact information for the reviewer.
URGENT PRIOR AUTHORIZATION REVIEWS
Requests identified as "Urgent/Expedited" must meet the following definition:
- An urgent care review request is for approval of care or treatment that, if delayed, could seriously jeopardize the patient’s life, health, ability to regain maximum function, or cause severe pain that cannot be managed without the requested care.
- Requests that are identified as "Urgent" that do not meet this definition cause unnecessary and possibly harmful delays in responding to other urgent requests.
UTILIZATION REVIEWS
Our goal is to provide high-quality care in the appropriate setting, at the right time, and by the most appropriate practitioner. Care management decision making is based only on the appropriateness of care, service, and the existence of coverage.
- Utilization management involves reviewing requests for coverage based on need and discussing coverage determinations.
- Staff are available at 1-800-289-1363 on weekdays from 8 a.m. to 5 p.m. PST. from 8 a.m. to 5 p.m. PST to answer questions about utilization review decisions.