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Bravo Health and delegated utilization review entities will involve actively practicing Providers in its
development of criteria and in the development and review of procedures in applying the criteria. Clinical
criteria will be reviewed regularly and shall be modified as required to reflect current medical standards.
PROSPECTIVE REVIEW PROCESS
Bravo Health requires prospective review of non-urgent/non-emergent procedures that require the use of
a facility other than the office. InterQual™, internally developed clinical guidelines, CMS guidelines,
National Decision Coverage Guidelines and Health Plan benefits/contract and coverage guidelines are
used to help make medical necessity determinations.
Decision Time Frames
Prospective review decisions on outpatient and inpatient elective procedures will be determined and
communicated electronically or in writing to Bravo Health , the Member and the healthcare Provider
within 14 days of receipt of the request. Bravo Health or the Member may extend this period an
additional 14 days if the delay is in the best interest of the Member. If the service requested can
adversely affect the Member’s life or function, an expedited determination may be made within 3 days
of the request, or as soon as required by the health status of the Member.
Prospective Utilization Review decisions shall be communicated via telephone and/or in writing to the
requesting Provider and Member in accordance with the Standard Maximum Time Frames identified
below:
• Emergent – Authorization not required using prudent layperson standards
• Urgent – within 48 hours or as soon as the Member’s health requires
• Expedited – within 72 hours or as soon as the Member’s health requires
• Routine – within 14 days
Authorization and/or denial or alternative treatment is the end result of prospective review.
While prospective review is preferable and must occur prior to planned care (e.g., elective admissions),
situations will exist when a prospective process is not feasible (e.g., emergency admissions) and/or does
not occur.
The Provider is responsible for the prior authorization of all scheduled admissions or services. The
Provider shall obtain prior authorization for admissions/services on a prospective basis, when possible,
and in a timely manner that ensures Member’s access to medically appropriate care.
Bravo Health’s Utilization Management (UM) Department is responsible for the prospective review of
admissions/services; the authorization ensures that the Member receives the proposed treatment in the
appropriate type of facility/location. The prospective review process shall occur only after the
authorization for proposed treatment is obtained by the Provider, when indicated by the Provider
Agreement . Without the Provider’s approval, an authorization number will not be issued.
1. The clinical information regarding the Member, the severity of the Member’s illness and
the proposed plan of care are assessed and evaluated by UM. The guidelines listed above
are utilized for screening medical and surgical care for the first level review. Examples of
information needed include, but are not limited to:
