Clinical review

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:

• Members’ clinical needs and benefit plans
• Well-established clinical decision-making support tools
• Appropriateness of care
• Centers for Medicare & Medicaid Services guidelines
• Health care objectives
• Clinical criteria based on current evidence in widely used treatment guidelines or clinical literature in the context of provider- or member-supplied clinical information and other relevant information
• Medical policies: We follow Medicare Advantage policies and criteria to decide when medical services are reasonable and necessary. As needed, we may also use our medical policies.

Prior authorization

We update prior authorization requirements quarterly to align with program or code changes. Please refer to our prior authorization requirements [PDF] before delivering planned services.

You can request prior authorization in multiple ways:

Refer to our provider manual for more information.