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a. Member name and identification number
b. Location of service, e.g., hospital or ambulatory surgery setting
c. Primary Care Physician name
d. Attending physician
e. Date of service
f. Diagnosis
g. Surgery, if applicable, with CPT code
h. Clinical information supporting the need for the service to be rendered
2. If the information regarding the Member, the severity of the Member’s illness, and proposed plan of
care meet the criteria for the establishment of medical necessity for inpatient care, outpatient procedure or
surgery, or other required services needing prior authorization a length of stay is assigned. This information
is entered into the Electronic Data Record and approval is communicated to the Provider and the hospital
within 2 days of the determination either via facsimile or in writing if denied.
3. If the information regarding the Member, the severity of the Member’s illness and the proposed plan of
care do not meet the criteria for the establishment of medical necessity; the attending Provider is advised
that the case will be referred to the Medical Director for review. UM Staff will advise the Provider that
he/she can contact the Medical Director for further discussion regarding the case. The Provider will also be
advised that the Medical Director will also attempt to contact him or her. If the case is approved by the
Medical Director, UM will notify the attending Provider of the authorization.
4. In the case of adverse determinations for the Member, UM will:
• Notify the PCP and/or attending Provider, Bravo Health and enrollee of the denial and the Appeal
process including time frames and methods for filing an Appeal.
• Generate a notice of adverse determination to the attending Provider and the Member within two (2)
business days of the determination or within 14 days of receipt of the request, whichever is less either
via facsimile or in writing.
5. If the prospective review does not occur prior to the procedure (e.g., the procedure was performed on an
urgent basis) a review will be conducted within twenty-four (24) hours of notification of the procedure.
6. Prospective or pre pre-service authorization is valid for ninety (90) days from the date of issuance. All
prospectively reviewed treatment, which is not begun within ninety (90) days from the date of issuance, will
require another pre-service review.
7. Pre-service review procedures will include provisions for the identification of Members with special
circumstances who may require flexibility in the application of screening criteria and for those for whom
case management services would be appropriate.
8. The information regarding the medical necessity for an approval of a prospective review request will be
accepted from any source including, but not limited to, phone, facsimile, and/or written correspondence and
can be initiated by any of the following entities: Provider, Member or authorized representative of the
Member.
