Prior Authorizations:
Prior authorization (pre-service requests) allows for the use of quality,
cost-efficient covered health care services and helps to ensure that effective
transition of care planning is done so that members receive the most
appropriate level of care within the most appropriate setting. Prior
authorization must be obtained for all services not included on the Quick
Authorization Form (QAF) for PCP’s (see section above) that require an
authorization.
SHP’s UM Department evaluates requests for services/procedures and makes
determinations based on medical necessity, covered benefits and appropriateness
based on SHP’s approved utilization criteria (Interqual) and evidence-based,
nationally recognized clinical guidelines. Only a Medical Director may issue an
adverse determination, with the exception of denials due to benefit issues. No
provider or any other individual or SHP employee or associate is rewarded for
issuing denials of coverage or care. Financial incentives will NOT encourage
decisions that would result in underutilization nor are incentives to create
barriers to care and services.
Prior Authorization Requests are to be made through the SHP’s UM
Pre-Certification Department.
Prior Authorization or Notification Process:
* Providers are to fax the Referral & Authorization Form (refer to
Forms Section) to the SHP’s Utilization Management Pre-Certification Department
at Fax number 1-800-283- 2114 or by calling the PreCertification Telephone
Queue 1-800- 887-6888, ext 2271.
* Routine (NOT STAT/URGENT) requests are processed within fourteen (14)
calendar days of the Plan receiving the authorization request and having
received all supporting clinical information.
STAT/URGENT requests are processed within seventy-two (72) hours of the Plan
receiving the request and having received the supporting clinical information.
NOTE: STAT/URGENT Authorizations should be CALLED IN to the SHP
Pre-Certification Authorization Telephone Queue and NOT faxed, and the caller
should identify the request as “STAT/URGENT”. These requests should always meet
the defined medical criteria for such which are:
STAT/URGENT: Any condition where failure to issue an immediate response may
result in an IRREVERSIBLE SIGNIFICANT, ADVERSE outcome of health and/or
function.
* The Referral & Authorization Form must be accompanied by supporting
clinical information for medical necessity determination
* An authorization number will be provided, via fax, to the PCP,
specialist and other provider(s) that will provide services to the member, when
the request is completed and approved
* All authorization requests and documentation of supporting clinical
information will be entered and maintained within the SHP computer system for
future reference and claims payment
When faxing a Prior Authorization Request, the SHP Referral &
Authorizations Form must be completed. The requesting provider is reminded to
include:
* Member demographic information (i.e. name, sex, DOB, SHP Member
Number)
* Provider demographic information
* Requesting provider (i.e. name, SHP Provider Number, phone number, fax
number, contact person)
* Referred-to specialist/facility (i.e. name, SHP Provider Number, address,
phone number, fax number, date of service, and identification if PAR (Plan
participating provider/facility) or Non-PAR (not a Plan participating
provider/facility)
* Diagnoses for authorization request, including ICD-9 Code(s)
* Procedure(s) for authorization request, including CPT/HCPCS Code(s)
* Number of visits requested, frequency and duration
* Pertinent medical history and treatment, laboratory and/or radiological
data, physical examinations/referrals that support the medical necessity for
the requested service(s)
Requests that do not meet medical necessity, based upon approved criteria are
reviewed by the Medical Director for a final determination. The Medical
Director may conduct a peer-to-peer discussion with the requesting provider, if
indicated.
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