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b. The Provider may make their requests via facsimile, phone or letter for pre-authorization before
scheduling the service.
c. The Medical Director reviews any request that does not meet Bravo Health’s criteria.
d. All Member requests for second opinions and recommendations for second opinions will be
provided within the network whenever the opportunity exists. Bravo Health does not require second
opinions for procedures.
e. Except for eligibility and benefit coverage denials, all denial determinations are made at the Medical
Director level.
f. Member eligibility is noted. Benefit level(s), indication of other insurance, and
limitations/exclusions are noted.
g. Prior authorization guidelines/clinical practice guidelines/medical necessity criteria are utilized as
part of the review. Guidelines will be provided to physician upon request.
h. A written description identifying the information that is collected to support decision-making is
maintained.
i. An appropriate licensed medical professional supervises all the review decisions.
j. Physician consultants from the appropriate specialty areas of medicine and surgery are utilized if the
reviewing Medical Director deems necessary.
k. Each request will be approved, denied or an alternative Covered Service may be suggested.
l. A request may be pended, in order for additional information to be obtained as requested. In these
cases, the requesting Provider will be contacted by phone or facsimile within twenty-four (24) hours
by Bravo Health to obtain the required information. If the addition al information is not received
within 14 days Bravo Health will issue a determination based on the clinical information submitted.
Discharge Planning
Discharge Planning is a critical component of the process that begins with an assessment of the patient’s
potential discharge care needs to facilitate the transition from the acute setting to the next level of care.
It includes preparation of the patient and his/her family for any discharge needs along with initiation and
coordination of arrangements for placement and/or services needed after acute care discharge. Bravo
Health’s Utilization Staff will coordinate with the acute care discharge planning team to assist in
establishing a safe and effective discharge plan. The Bravo Health Utilization Review nurse will
provide all needed discharge authorizations for services, equipment and skilled needs.
