Preauthorization, Concurrent Review, Case Management, and Care Coordination

Preauthorization, concurrent review, case management, and Care Coordination are designed to ensure:

  • Your health care expenses are medically necessary,
  • Your care is delivered in an efficient, cost-effective manner, and
  • Your eligible medical expenses are reimbursable by the Plan.

Preauthorization means getting approval — before a treatment occurs — to confirm that the treatment is medically necessary. To request preauthorization (also known as “precertification”), your provider must call the Health Plan’s Utilization Management (UM) Department at (877) 563-7427.

It is your responsibility to call the UM Department to verify your provider has obtained preauthorization before receiving services. If so, the UM Department can tell you the preauthorization number for your procedure (you should write it down for your records).

Penalty for Failure to Obtain Preauthorization: If you or your provider does not obtain preauthorization when it is required, a 25% benefit penalty (100% benefit penalty for transplants) per event will be added to your share of the medical expenses. In addition, if these services are later found not to be medically necessary, claims for reimbursement will be denied.

Example: Assume you get a CT scan in-network and that the Health Plan would normally pay $1,000 for the scan. If you or your provider does not obtain preauthorization, the Plan will pay only $750 (assuming the scan is medically necessary). You would be responsible for the remaining $250 as your benefit penalty, in addition to any other expenses that are your responsibility under the Plan.

Please also note the following two special rules:

  • Failure to obtain preauthorization for a Human Organ or Bone Marrow Transplant will result in a 100% benefit penalty (in other words, the Plan will not cover any of the transplant expenses).
  • Charges for the use of a robotic surgical system (for example, robot-assisted prostate surgery) are not eligible expenses unless such charges are specifically preauthorized by the Plan's UM Department.

The following sections describe the services and products for which preauthorization must be obtained. For a detailed listing, see “Appendix C: Services that Require Preauthorization.”

Preauthorization only means getting approval that the requested services are medically necessary. It is important to note that:

  • Preauthorization is not intended to be a substitute for the medical judgment of your doctor or other health care providers. In addition, preauthorization is not required for emergency services — meaning medical services that a reasonable person with an average knowledge of health and medicine could reasonably expect to be needed to avoid placing the life or health of an individual, or the ability to regain maximum function, in serious jeopardy or to avoid serious impairment to bodily functions or serious dysfunction of a bodily organ or part. Preauthorization is also not required for urgently needed care. Please note, however, that you are required to contact the Plan’s UM Department within two business days following an unscheduled inpatient admission, as discussed below. 
  • Preauthorization is based upon the information presented by the participant or his or her provider at the time preauthorization is requested. Preauthorization does not guarantee that the services and products a participant receives are eligible for benefits under the Plan, or that each itemized charge will be covered. At the time the participant’s claims are submitted, they will be reviewed in accordance with the terms of the Plan. The final determination of whether the services and products are eligible expenses is subject to all conditions, exclusions, and limitations of the Plan. For example, if you receive preauthorization for inpatient care, the services and products you receive during your inpatient stay will be subject to review for compliance with Plan terms. If you receive excessive or unnecessary services, for example, the claims for those services are subject to denial even though the inpatient admission was preauthorized.

Inpatient Care – Scheduled and Unscheduled Admissions

Preauthorization must be obtained for all scheduled inpatient admissions before the stay (except for certain childbirth stays) and for transition care when moving from one type of inpatient care to another (for example, moving from inpatient hospital care to a skilled nursing facility). For maternity admissions, preauthorization must be obtained only for stays longer than 48 hours following a vaginal delivery, or 96 hours following a cesarean section.

The process for requesting this preauthorization is described in the section “Preauthorization Process for Scheduled Care.”

For unscheduled admissions, such as an admission following emergency room care, preauthorization must be requested within the next two business days. The process for requesting this preauthorization is described in the section “Preauthorization Process for Unscheduled Admissions.”

If you or your provider requests to extend care beyond the preauthorized length of stay and that request involves urgently needed care, the Plan's UM Department will notify you or your provider whether the extended stay is medically necessary within 24 hours, as long as the request is made at least 24 hours before the end of the preauthorized length of stay. If the request does not involve urgently needed care, the normal timeframes for responding to a preauthorization request will apply.

For purposes of the preauthorization requirements, following are examples of facility types considered to be “inpatient admissions.” For clarity, the Place of Service (POS) code designated for each facility type by the Centers for Medicare & Medicaid Services (CMS) is provided in parentheses. This list of examples is not exhaustive and may change from time to time.

  • Birthing Center (25)
  • Comprehensive Inpatient Rehabilitation Facility (61)
  • End-Stage Renal Disease Treatment Facility (65)
  • Hospice (34)
  • Inpatient Hospital (21)
  • Inpatient Psychiatric Facility (51)
  • Residential Substance Abuse Treatment Facility (55)
  • Psychiatric Residential Treatment Facility (56)
  • Skilled-Nursing Facility (31)

Outpatient Care

Outpatient care may be provided in a variety of settings, such as a physician’s office, your home, an ambulatory surgery center, or an imaging center. But it can also be provided in a hospital, such as when you are getting emergency department services, observation services, outpatient surgery, lab tests, or X-rays. For purposes of the preauthorization requirements, the following are examples of outpatient facility types in which care must be preauthorized. For clarity, the Place of Service (POS) code designated for each facility type by the Centers for Medicare & Medicaid Services (CMS) is provided in parentheses. This list of examples is not exhaustive and may change from time to time.

  • Home (12)
  • Off-Campus Outpatient Hospital (19)
  • On-Campus Outpatient Hospital (22)
  • Ambulatory Surgical Center (24)

Services (including routine visits or procedures) performed in a physician’s office (POS 11) do not require preauthorization unless the services are specifically listed in "Appendix C: Services and Products That Require Preauthorization."

Preauthorization must be obtained for the following outpatient services:

  • Dialysis (effective July 15, 2017)
  • Genetic testing (effective July 15, 2017), except not required for CPT code 81420 if the patient is age 35 or older
  • Home health care services, including but not limited to:

    • Home occupational, physical, or speech therapy (limited to 25 visits per year for each type of therapy)
    • Home infusion therapy
    • Hospice care

  • Infusion services (e.g., chemotherapy, biological therapy)
  • MRI, CT, echocardiography, and other imaging*
  • Outpatient procedures
  • Oxygen (home and/or portable)
  • Private-duty nursing

*Preauthorization is not required for X-rays or routine ultrasounds.

The process for requesting this preauthorization is described in the section “Preauthorization Process for Scheduled Care.”

If you have questions about whether a specific outpatient service requires preauthorization, please review “Appendix C: Services that Require Preauthorization” or call the Plan’s UM Department at (877) 563-7427.

Durable Medical Equipment

Preauthorization must be obtained for certain types of durable medical equipment items, as listed in “Appendix C: Services that Require Preauthorization.” The process for requesting this preauthorization is described in the next section. 

Preauthorization Process for Scheduled Care

When preauthorization is required for scheduled care (scheduled admission, outpatient care, and durable medical equipment as described above), you or your provider must request preauthorization by calling the Plan’s UM Department at (877) 563-7427 as soon as possible before the procedure, inpatient admission, outpatient service, purchase or rental of durable medical equipment, or transition care (for example, from inpatient hospital care to a skilled nursing facility, home health care, or hospice care).

When you or your provider request preauthorization for scheduled care, the Plan's UM Department will provide a written response to your or your provider's preauthorization request within 15 days, unless additional time is needed. If additional time is needed, the UM Department will notify you within the original 15 days that additional time is necessary. Please keep this response period in mind when requesting preauthorization. If you or your provider do not allow enough time for your request to be reviewed, you may not receive preauthorization and you may be subject to the benefit penalty.

If the Plan’s UM Department requests additional information from you, you will have 45 days to provide the information. The Plan’s UM Department will provide a written response within 15 days of receiving the additional information.

When the Plan’s UM Department preauthorizes scheduled care, they will provide you and/or your provider with a preauthorization number, beginning with “EPS.”

If you disagree with the Plan’s UM Department's determination regarding your preauthorization request, you can file an appeal. See "How to File a Claim" for more information about the claim and appeals process.

Please note: When your provider requests preauthorization on your behalf, the Plan may communicate directly with that provider to facilitate the review process. However, obtaining preauthorization remains your responsibility.

Preauthorization Process for Unscheduled Admissions

If your admission to the hospital is unscheduled — such as an admission from the emergency room — you may not be able to request preauthorization before your admission occurs. In that situation, you or someone on your behalf must call the Plan's UM Department at (877) 563-7427 within the first two business days after the admission. (For example, if you go to the emergency room on Friday night and are admitted to the hospital on Saturday, you should call the UM Department by 5 p.m. CT on Tuesday.) Outside of business hours, you may leave a confidential voice mail message.

When you or your provider requests preauthorization for an unscheduled inpatient admission, the Plan’s UM Department will provide a response to your or your provider's preauthorization request within 72 hours, unless additional time is needed. If additional time is needed, the Plan’s UM Department will notify you within the first 24 hours that additional time is necessary.

If the Plan’s UM Department requests additional information from you, you will have a minimum of 48 hours to provide the information. The Plan’s UM Department will provide a response within 48 hours of whichever of the following events occurs first:

  • Receipt of the additional information, or
  • The end of the time period you were given to provide additional information.

The Plan’s UM Department responses may be issued orally, in which case a written response will also be provided within three days of the oral notification.

When the Plan’s UM Department preauthorizes an unscheduled admission, they will provide you and/or your provider with a preauthorization number, beginning with “EPS.”

If you disagree with the Plan’s UM Department's determination regarding your preauthorization request, you can file an appeal. See "How to File a Claim" for more information about the claim and appeals process.

Please note: When your provider requests preauthorization on your behalf, the Plan may communicate directly with that provider to facilitate the review process. However, obtaining preauthorization remains your responsibility.

Concurrent Review

The Plan provides concurrent review to determine whether the services you are receiving during an ongoing course of treatment (such as a hospitalization or a course of physical therapy sessions) are medically necessary. Concurrent review monitors your inpatient care and coordinates the scheduled release with you, your providers, and any alternative care you may need. Concurrent review can also identify other courses of treatment, such as home health care and home intravenous therapy.

Care Coordination

The Health Care Program provides services and requirements for complex or chronic conditions to help you receive medically necessary treatment and avoid gaps in care.

  • Centers of Expertise. For designated procedures, the Plan has identified Centers of Expertise. For more information, see “Centers of Expertise.”
  • Health Monitoring. Health monitoring helps you receive prompt medical attention when you are not in the hospital. Health monitoring provides electronic devices to transmit your real-time vital health indicators, such as blood pressure and heart rate, directly to your health care provider.
  • Treatment-Plan Review and Coordination. Care Coordination Services works with you and your health care providers to evaluate your options (including at-home services), help plan for continued care, and review your drugs. Care Coordination Services may require your provider to periodically submit a treatment plan for review as a condition for benefit coverage.

Although Care Coordination is intended to help you have a better health care experience, the Health Care Program and the participating employers are not health care providers, nor do they guarantee positive health outcomes, avoidance of complications, or avoidance of gaps in care.

Receiving Care Coordination

The Plan will determine whether Care Coordination is required when you:

  • Request preauthorization for services related to a complex or chronic condition (for example, cancer treatment, inpatient substance abuse treatment, or cardiothoracic surgery),
  • Have claims related to a complex or chronic condition,
  • Fail to complete a prescribed course of treatment, or leave a health care facility against medical advice,
  • Have home-health services or private-duty nursing, or
  • Have treatment involving three or more inpatient stays, or 30 or more inpatient days, within the preceding 12-month period.

You may also request Care Coordination by calling (855) 979-5206 (toll-free).

Benefit Penalty for Declining Care Coordination or Centers of Expertise

If Care Coordination is required for your condition, Care Coordination Services will contact you to offer assistance and the Plan will notify you in writing. If you decline required Care Coordination or choose not to comply with a recommendation from Care Coordination Services, or if you choose a provider other than a Center of Expertise for a designated procedure, a benefit penalty equal to 40% of the amount the Plan would normally pay will be applied to expenses related to the condition. This benefit penalty does not apply toward any deductibles or out-of-pocket limits.