Provider Guide - the Culinary Health Fund

Provider Guide October 2012
Prior Authorization/Utilization
Prior Authorization/Utilization Criteria
Services requiring prior authorization include both outpatient and inpatient services. Please refer to page
21 or the Culinary Health Fund’s website at www.culinaryhealthfund.org for a list of services that require
prior authorization. This list will be updated from time to time and it is the provider’s responsibility to
check the website for updates or contract Provider Services at 702-892-7313.
Approval does not guarantee that benefits will be paid. Payment will depend on whether the service is a
covered benefit; the service is within the scope of your Provider Agreement and whether the participant is
eligible at the time of service.
American Health Holding Inc., (AHH)
American Health Holding Inc. is the utilization/case management provider for the Culinary Health Fund.
They conduct prior authorizations, concurrent and retrospective reviews.
You may call American Health Holding authorization number at 1-866-330-2307 Monday through
Friday from 8am to 8pm EST, or you can use the online form at http://culinaryhealthfund.ahhinc.com/
to initiate a review. A staff person will record all of the demographics of the case, and if all the medical
information iIs available, the information will be given to a nurse for review.
HealthHelp
Effective August 1, 2012, the following requests will now be authorized by HealthHelp:
• Diagnostic Imaging: CT, CTA, MRI, MRA, PET and cardiac nuclear medicine scans.
• Medical Oncology treatments: chemotherapy, hormone therapy, biologics, supportive care medications.
• Radiation Oncology treatments: two-dimensional (2D) and three-dimensional (3D) conformal radiation,
intensity-modulated radiation therapy (IMRT), brachytherapy, stereotactic radiation therapy and
proton-beam procedures.
You may call the HealthHelp authorization number at 1-800-519-9935, fax the prior authorization request
to 1-800-592-9050 or you can use the website at http://www.healthhelp.com/culinary to request the
prior authorization.
These changes will NOT affect emergency department (ED) services or radiology services ordered while a
member is hospitalized.
Behavioral Health Authorization
All behavioral health, mental health, and chemical dependency services require prior authorization through
Harmony Healthcare at 702-251-8000 or 800-363-4874. Harmony Healthcare is available 24 hours a day, 7
days a week..
Medication Authorization
Catalyst Rx performs drug authorizations for specific medications. This list may be updated from time to
time. It is the provider’s responsibility to contact Catalyst Rx at 866-611-5960 for updates.
20 Culinary Health Fund Administrative Services, LLC