Clinical Information and Utilization Management Decision Making
Serra Community Medical Clinic (SCMC) will ensure that the following information is collected to support UM decision-making. The UM process shall ensure that information needed to make a determination of medical necessity has been collected.
Serra shall request medical information from the provider in order to determine whether to approve, modify or deny requests for authorization, Serra shall request only information reasonably necessary to make the determination and consults with the treating provider
Only Board-Certified Physician will participate in UM Decision making
PROCEDURE:
- SCMC will obtain clinical information from the ordering physician that is pertinent to the requested services.
- Clinical information to be obtained include at least the following:
- History of presenting problems.
- Clinical exam findings
- Diagnostic testing results
- Treatment progress notes
- Psychosocial history
- Information on consultations with the treating practitioner
- Evaluations from other health care practitioners and providers
- Photographs
- Operative and pathological reports
- Rehab evaluation
- Printed copy of criteria related to the request.
- Information regarding benefits for services or procedures
- Information regarding the local delivery system
- Information from patient and responsible family member
- HMO department will check health plan coverage to see if the requested services are covered.
- The medical record must reflect medical necessity for the requested services.
- A request for services will be sent to the HMO department for review.
- If all relevant information is collected and it shows medical necessity the referral is approved
- The member is called within 24 hours and the notice is sent within 2 working days.
- The Medical Assistant for the requesting physician is sent a task (PCM) within 2 working days with the status of the request.
- The MA makes the appointment for the services requested
- The referral request status is available immediately for the requesting physician to view.
- Timeframes are as follow:
- Routine request within 5 days of receipt of information.
- Imminent or serious threat to member health 72 hours.
- Providers notified by telephone of decision within 24 hours (all cases) followed by written notice within 2 (two) business days.
CMS
Extension allowed Only if member requests or the provider organization justifies a need for additional information and how the delay is in the interest of the member (for example, the receipt of additional medical evidence from non-contracted providers may change a decision to deny.
Pharmacy Request Prior Authorization (Health Net)
SMG will utilize the most current required DMHC Prescription Drug and Prior Authorization form for all prior authorization prescription request. The form is available on the Health Net provider website at provider/healthnet.com under Pharmacy information and in the Provider Library under forms. For HMO Commercial send by secure fax to (800) 314-6223 and for Medi-Cal send by secure fax to (800) 977-8226. Health Net will respond via fax to advise provider the status of the request. Request for HMO commercial members will be processed within 72 hours for non- urgent request and 24 hours for exigent requests. Request for Medi-Cal members will be processed within 24 hours.
Time frames for timeliness of Pharmacy Prior Authorization Request:
Serra adheres to the ICE UM Timeliness standards for CA Commercial HMO, CMS and Medi-cal for approvals, denials and modifications for medical necessity.
Commercial: CA Health & Safety Code section 1367.241(CA SB 282; 2015-2016)
- Urgent Concurrent-(exigent)decision and notification within 24 hours of the request.
- Urgent Preservice-(exigent) decision and notification within 24 hours of the request.
- Non-Urgent Pre-service- decision and notification within 72 hours of the receipt of the request
- Post Service- decision and written notification within 30 days of receipt of request.
Senior:
- Urgent Concurrent-decision and notification within 24 hours of the request.
- Urgent Pre-service-decision and notification within 24 hours of the request.
- Non-Urgent Pre-service- decision and notification within 5 or 14 days of the receipt of the request.
- Post Service- decision and written notification within 30 days of receipt of request.
Medi-Cal:
- Urgent Concurrent-(exigent) decision and notification within 24 hours of the request.
- Urgent Pre-service-(exigent) decision and notification within 24 hours of the request.
- Non-Urgent Pre-service- decision and notification within 5 business days of the receipt of the request, written notification within 2 business day so f decision.
- Post Service- decision and written notification within 30 days of receipt of request.
