2
PRIOR AUTHORIZATION .............................................................................................................................................................35
General Rules .........................................................................................................................................................................35
Authorization Rules by Place of Service................................................................................................................................36
In Office...................................................................................................................................................................36
Inpatient....................................................................................................................................................................37
Outpatient.................................................................................................................................................................38
Ambulatory Surgery Center .....................................................................................................................................40
Home Health Services..............................................................................................................................................40
Preventive Care........................................................................................................................................................41
Health and Wellness.................................................................................................................................................42
Medicines and Injectibles.........................................................................................................................................43
Prior Authorization Request Form ...........................................................................................................................45
QUALITY IMPROVEMENT............................................................................................................................................................46
Quality Improvement Program...............................................................................................................................................46
Healthcare Effectiveness Data and Information Set...............................................................................................................47
ON-SITE ASSESSMENTS ................................................................................................................................................................48
Office Standards.....................................................................................................................................................................48
Medical Record Review .........................................................................................................................................................48
HEALTH SERVICES ........................................................................................................................................................................50
Goals.......................................................................................................................................................................................50
Clinical Review Guidelines....................................................................................................................................................50
Prospective Review Process...................................................................................................................................................51
Decision Time Frames............................................................................................................................................................51
Concurrent Review.................................................................................................................................................................53
Retrospective Review.............................................................................................................................................................53
Referrals to Non- Contracted Providers..................................................................................................................................53
Ambulatory Services ..............................................................................................................................................................53
Discharge Planning.................................................................................................................................................................54
Case Management...................................................................................................................................................................55
Skilled Nursing Care ..............................................................................................................................................................55
Emergency Services ...............................................................................................................................................................55
Decision Time Frames............................................................................................................................................................56
DENIALS.............................................................................................................................................................................................56
Rendering Denials ..................................................................................................................................................................56
Notification of Denials ...........................................................................................................................................................56
CONTINUITY OF CARE..................................................................................................................................................................
57
CLINICAL PRACTICE GUIDELINES ..........................................................................................................................................58
Congestive Heart Failure........................................................................................................................................................58
CHF Pharmacological Treatment Options..............................................................................................................................59
Heart Failure Disease Classification.......................................................................................................................................60
Diabetes..................................................................................................................................................................................61
Coronary and Other Vascular Disease....................................................................................................................................62
COPD .....................................................................................................................................................................................64
PHARMACEUTICAL MANAGEMENT ........................................................................................................................................65
Step Therapy...........................................................................................................................................................................65
Prior Authorization.................................................................................................................................................................66
ALTERNATIVE DISPUTE RESOLUTION ...................................................................................................................................67
ADULT PREVENTION AND SCREENING GUIDELINES.........................................................................................................71
