Home For Providers Provider Manual Changes to the Prior Authorization List and Utilization Guidelines for 2012

Changes to the Prior Authorization List and Utilization Guidelines for 2012

Changes to the Prior Authorization List are based on semi-annual reviews of factors such as utilization performance against benchmarks, changes in standards of medical care, new technology, or denial rate. See the lists below for a summary of the changes from 2011 to the 2012 Prior Authorization List and Utilization Guidelines:

• Deleted from the 2012 Prior Authorization List
• Changed on the 2012 Prior Authorization List
• Added to the 2012 Prior Authorization List
• Clarified on the 2012 Prior Authorization List

Deleted from the 2012 Prior Authorization List

• CT head (non-emergent)
• Behavioral health > 8 visits

Changed on the 2012 Prior Authorization List

Added to the 2012 Prior Authorization List

• Bariatric surgery
• Tonsillectomy
• Chemical dependency/substance abuse: Prior authorization required for all outpatient and inpatient treatment (Basic Health /Washington Health Program/ Medicare)
• Mental health:
  • Planned inpatient psychiatric services require prior authorization.
  • All admissions (planned and urgent) require notification of admission within 24 hours or next business day.
• Added drugs:
  • Actemra (tocilizumab)
  • Denosumab (Prolia or Xgeva)

Clarified on the 2012 Prior Authorization List

• Durable medical equipment (DME), prosthetics, and medical supplies:
  Please note: It is the Plan's policy to require prior authorization for each DME, prosthetic and supply with a purchase price on the HCA fee schedule that exceeds $1,000. DME benefits are not covered by Care Management Services (Disability Lifeline) and Basic Health regardless of purchase price.
• Home services:
  • Home health
  • Enteral/parenteral services
  • Infusion
  • Therapy (physical/ occupational/ speech therapy)
• Instruction page:
  • Documentation required to support decision-making—Clarified with examples of appropriate documentation for medical necessity reviews.
  • Referral policy—Clarified language regarding when a PCP is required to submit a referral request to the Plan and process around out-of-network and PCP-to-PCP referrals.
  • Inpatient hospitalizations—Clarification regarding notification of admission for all admissions, planned and unplanned, within 24 hours of admission or next business day.
  • Submitting your request—Added new section regarding use of Care Management Portal for online prior authorization requests, online admission notifications, eligibility checks, and authorization request status checks. List of contact information.