Utilization Management

Utilization Management (UM) helps us work with your doctors to give you the right care at the right time, and in the right setting. We care about your health and wellness and want to make certain the care you receive is of high quality and value.

If you are provider, view utilization management information for providers here.

Prior Authorization and Notification

What is prior authorization?

Prior authorization is a tool used within Utilization Management. It’s a screening review process of select medical care or services before you get that care. You and your provider will decide what healthcare you need and our review does not take the place of the advice from your provider. Our prior authorization review allows us to work closely with your provider, partnering so you receive high-value care. As stewards of your healthcare resources, prior authorization is a check and balance, helping to make sure the care you receive is safe, effective and affordable.

When we review requests for prior authorization, we use the medical information submitted by your provider, your specific plan coverage and benefits, and clinical review criteria and standards that are objective and evidence based. This is criteria that your provider knows and trusts and is widely recognized. Qualified health professionals, such as doctors and nurses, review prior authorization requests and make decisions. Our process supports fair and timely reviews and can reduce costs by making sure there’s not another affordable treatment that’s equally effective or other opportunities for you to receive care in your provider network. For more information on prior authorization and the clinical review criteria we use, click here.

Who requests prior authorization?

Physicians and other healthcare providers are responsible for requesting prior authorization with us or with our partner, eviCore Healthcare.

* Before any procedure or lab work, it’s a good idea to check with your provider to see if they have contacted us to verify if prior authorization is needed

You can check your benefits, coverage and which services require prior authorization – so you know what’s covered before you have services performed or appointments made. Log into your member portal at hally.com or call the number on your health plan ID card if you’d like more information, or if you’d like a copy of your coverage documents mailed to you. To locate providers in your network, use our Find Care search tool here.

* Health AllianceTM partners with eviCore Healthcare for certain prior authorization services.

How can I request prior authorization?

Check with our Customer Solutions department by calling the number on your health plan ID card. They can see if your provider has requested prior authorization before you get any services.

If your provider has not requested prior authorization, our Customer Solutions team can help you begin the process.

How does the prior authorization process work?

Health Alliance, or our partner eviCore Healthcare, will review the requested service using evidence- based criteria to determine if it’s medically necessary.

To complete a prior authorization request, here’s what we’ll need:

• Your name, health plan member ID number and date of birth.
• Your provider’s name, address, phone number and National Provider Identifier (NPI).
• Information about your health condition (your medical records from your provider).
• The treatment plan your provider is recommending, including any diagnosis and procedure codes.
• The date you’ll need to receive the service and for how long.
• The place you’ll be treated.

Prior authorization may be required for some outpatient services such as planned elective surgeries, durable medical equipment, specialty visits, certain inpatient services or post-acute care like admission to a skilled nursing facility.

Prior Authorization for Inpatient Acute and Post-Acute Care in a Facility

Notification of Your Hospital Admission and Your Stay

Utilization Management also takes place during hospitalization. Acute-care hospitals are responsible for notifying us of your admission for inpatient services within 24 hours of your admission, even if you have an authorization for an elective surgery or treatment already on file. We’ll work closely with the hospital care team to collect information on your condition and progress, and determine ongoing coverage based on this information. When you’re in the hospital, we’ll help make sure you get the right level of care at the right time. Throughout your stay, our Utilization Management nurses, social workers and physician medical directors will assess and help with your care, your discharge from the hospital and beyond. Our goal is for you to receive safe and high-quality care. To help you navigate your care after you go home, we’ll identify whether you might benefit from one of our covered care coordination programs, such as Care Transition Intervention, health coaching and disease management, specialty or complex care coordination, or something else.

Emergency Services

If you should require emergency inpatient services, the facility you’re admitted to should also notify Health Alliance of your admission within one business day.

Prior Authorization for Post-Acute Care in a Facility

Post-acute care is a special type of care that you may need following a stay in the hospital. The care focuses on helping you regain your level of function you need to go home. Post-acute care can take place at a skilled nursing facility, long-term acute-care hospital or an acute inpatient rehabilitation facility. Your discharging provider at the hospital will work with you to determine your options for care and at which facility you wish to receive your care. Your provider is responsible for sending us a request for prior authorization before you’re admitted for this type of post-acute inpatient care. Once your post-acute care is approved and you’re admitted for care, we’ll work together with your provider to stay informed of your care needs and help plan the next steps when you no longer require post-acute care.

If you received skilled care in a skilled nursing facility and no longer need skilled services, you may return home independently, return home with home health services, seek a residence at an assisted living center or choose to remain in a nursing facility with custodial care. Custodial care is nonskilled personal care that doesn’t require daily skilled medical services. Some examples of custodial care include help with bathing, dressing, eating, using the bathroom, or getting in and out of bed. Although your provider might recommend custodial care, if it’s the only care you need, in most cases, this type of long-term care is not covered by Medicare or your health plan.

To assist you with navigating your healthcare, we’ll connect you with our Hally® care coordinators at no cost. This is a free service that we provide to aid you in your health. Care coordinators work with you, your doctors and your nurses to help you get the most out of your coverage and help you manage your health conditions. If you plan to receive care in a larger, tertiary care center or with a provider who’s out of your network, our care coordinators can help you with your journey. To learn more about Hally health and care coordination click here.

Prior Authorization Statistics Reporting and Criteria

Pharmacy Policies

Prior Authorization and Clinical Review Criteria

Appeals

If you have a complaint, or if you’re unhappy with coverage for care or a service being denied, in certain situations, you have the right to file an appeal to review the denial again.

Notes

For the purposes of this policy, "coverage" means either the determination of (i) whether or not the particular service or treatment is a covered benefit pursuant to the terms of the particular member's benefits plan, or (ii) where a provider is required to comply with Health Alliance Utilization Management programs, whether or not the particular service or treatment is payable under the terms of the provider agreement.