SCI Preauthorized Payment Authorization Form - Lovelace Health ...

Dear [Member][Prospective Member]:Below please find information you requested about the process by which Lovelace Health Plan authorizesor denies services and the criteria and protocols we use when making utilization managementdetermination.“A. Prospective Review (Precertification):Processes:The care needs when associated with a procedure, service or diagnosis are considered foreach individual member. Proactive assistance to the member, the member’s family andprovider in meeting those needs is available through data gathering, determining memberbenefits, determining member eligibility and the referral process.Prospective review incorporates a criteria based model utilizing:Milliman Care GuidelinesLovelace Criteria SetsManaged Physical/Occupational Therapy Rehabilitation Care Manual (Apollo)Managed Care Organizations Uniform Level-of-Care GuidelinesMedicare Coverage GuidelinesECRI, formerly known as Emergency Care Research InstituteCoverage Position Criteria for CIGNA MembersFederal and State Mandates for Coverage DeterminationThe Medical Director or physician reviewer makes determinations on all requests for medicalservices or supplies that the clinical reviewer is unable to approve. Potential denials shall bereviewed according to existing policies, procedures and protocols.Health Services clinical staff may administratively deny authorization of services that are nota covered benefit. All denials will be communicated in writing to the affected parties. Denialletters include the following information:The specific reason or reasons for the denial including the criteria used in thedetermination.Alternative treatments or providers (for those non-contracted).Appropriate information as to the steps to be taken should the member/provider wishto appeal the decision and/or request a fair hearing, including the opportunity todiscuss the case with the Medical Director.

The department adheres to the decision and notification standards consistent with NCQA, DOI and CMSregulations.Certain specified services and levels of care require a coverage determination andprecertification number as part of our program (Reference policy 2.03.02, Precertification).This process provides the opportunity for Health Services to determine benefit coveragestatus, assist with coordination of care needs and identification of catastrophic and chroniccases that may benefit from care coordination and case management. It also provides anopportunity to redirect care to more appropriate levels of care and credentialed providers.This includes use of the Company’s contracted Transplant Network centers for organ andtissue transplant evaluations and transplants. The Company does not require prospectivereview of emergency services (Reference policy 2.03.12, Emergency Services, and 2.03.30,Emergency Services – Medicare).B. Concurrent Management and Discharge Planning:Continuity of care is enhanced through pre and post admission and outpatient proceduretreatment plan review, evaluation of progress against the treatment plan and facilitating theplan of care through anticipation of care needs, identification of contracted providers andavailable benefits and communication with the treating providers.Inpatient continued stay review may be done telephonically, via fax or on-site at facilities,including but not limited to acute care facilities, skilled nursing facilities, long-term acute careand acute rehabilitation facilities.These processes include assisting the providers and members with coordinating treatmentplans to maximize services available within the member's health care benefit plan,coordination of care between third party payers, community resources, and the Company andto smoothly transition care across the continuum of inpatient and outpatient settings. Thisrequires effective communication with providers and members with a goal of improved healthoutcomes and enhanced member satisfaction.Milliman Care Guidelines is referenced to assess the level of care, treatment plan andprogress of member within the treatment plan. Additionally, the guidelines assist the staff toanticipate and work with the treatment team to plan for other care needs associated with theircondition or procedure and to recognize cases appropriate for further review by theCompany’s Medical Director.Case Review Rounds are conducted to review hospitalized members, and members open toCase Management, to identify possible care alternatives and to identify opportunities toimprove timing and access to covered services. Case Review Rounds participation includesthe Medical Directors, Behavioral Health Associate Medical Director, Directors, Managers,nurses, social workers and other disciplines as needed. Continued inpatient cases receive

Medical Director oversight through Medical Director discussions with Patient CareCoordinators and Case Managers.C. Retrospective Review:Processes:Retrospective review is a multi-dimensional process. It includes gathering detailed clinicaland financial data after services have been incurred to evaluate utilization patterns. TheCompany may assess various information parameters, which may include but are not limitedto in whole, by product type, physician (PCP and Specialist), delegated entity (whenapplicable), facility provider type, disease condition, activity and referral pattern. The datamay be used to identify opportunities for action or follow-up, e.g., utilization patterns (overand under relative to comparative norms), for credentialing review or to educate providersand to improve the Health Services Program.The Company may review ER claims retrospectively in order to identify members who utilizeemergency services inappropriately. Identified members are offered case managementservices in order to assist and educate them to use appropriate alternative services such asthe New Mexico Nurse Advice Line and their PCP’s office.,Additionally, the Company’s utilization systems and the Data Warehouse houses utilization,claims and encounter data on the Company’s physician and hospital providers. This data isused to retrospectively evaluate physician behavior, counsel providers to improveperformance, and evaluate providers in conjunction with quality and service data for overalleffectiveness. These processes include assessments of both over and under utilization ofservices. Additionally, this data can show population-based or regional trends and may fosterquality improvement or other activities