Clinical review
We coordinate health care for our members to ensure they receive quality, timely and clinically appropriate care.
We or one of our delegated vendors will administer utilization management review and care management services. Except in the case of an emergency medical condition, we’ll provide prior authorization for those services if required by the member’s benefit plan, including hospital inpatient stays or confinement.
You should become familiar with and follow our program requirements. We may require you to provide medical records and other information, including access to electronic health records.
We base utilization-related decisions on our members’ clinical needs, benefit plans and appropriateness of care employing well-established clinical decision-making tools. We also consider current evidence in widely used treatment guidelines and clinical literature, taking into account information provided by the provider or member. Criteria we may consider during the clinical review process include:
Centers for Medicare & Medicaid Services’ National Coverage Determinations
American Society of Addiction Medicine clinical guidelines
HealthSpring medical policies
EviCore clinical guidelines
American Specialty Health medical coverage policies
WellMed® medical coverage policies
HealthSpring member handbook
Member Evidence of Coverage
Prior authorization
You can request prior authorization in multiple ways:
Through our self-service portal: Log in to Availity® Essentials to verify a member’s benefits, coverage and eligibility. After confirming, access the prior authorization portal through the HealthSpring Medicare Advantage payer space and submit all supporting documentation.
Or submit to us: Refer to our prior authorization forms. Complete the forms in their entirety and attach pertinent clinical information.
Mail to:
HealthSpring
Attn: Prior Authorization
500 Great Circle Road
Nashville, TN 37228
Call or fax:
| Contact | Phone | Fax |
|---|---|---|
| Behavioral health | 1-866-780-8546 | 1-866-949-4846 |
| Drugs or biologics Part B | 1-888-454-0013 | 1-877-730-3858 |
| CareAllies | 1-844-359-7301 | 1-866-233-6235 |
| Clinical operations | 1-800-453-4464 | 1-866-287-5834 |
Refer to our provider manual for more information.