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Precertification & Medical Criteria

Precertification & Prior Authorization

Most of the time, groups utilizing the HealthSpan provider networks must also use HealthSpan’s care management which can include all or some of the services listed below:

  • Utilization Review
  • Case Management
  • Health Coaching
  • Disease Management (Help with Chronic Conditions)
  • Health Risk Assessments
  • Wellness Programs (Healthy Living)
  • Predictive Modeling

Utilization Review includes Precertification or Prior Authorization. The purpose of Precertification is to establish medical necessity prior to services being rendered. In some cases, Precertification is needed to establish whether services can be rendered at a given location or provider type based on the terms of the plan.

An approval of medical necessity is not a guarantee of eligibility or benefit coverage. Providers should always contact the administrator or insurer on the member’s ID Card to determine if a service request is a covered benefit for the member.

Services requiring precertification vary by plan. HealthSpan makes annual recommendations to plan sponsors. Click here to review our standard precertification list for 2013. You can use the Provider Login to look up whether the member’s group uses our standard list or an alternative. Please be sure to call to ensure you meet the provisions of each plan as changes may occur at any time.

Click here to obtain Precertification Forms

Medical Criteria

HealthSpan utilizes evidence-based medical guidelines when determining medical necessity. The use of these guidelines supports care delivery with the goal to remove unnecessary variation by different reviewers when making decisions.

Below is a list of the guidelines used by the HealthSpan staff:

  • Milliman Care Guidelines
  • National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines
  • Official Disability Guidelines (ODG)
  • Up-to-Date Database
  • Medicare Guidelines

HealthSpan’s Case Management works with the HealthSpan Medical Advisory Committee (MAC) on guideline development, approval, and implementation to assure subsequent measurement adherence.

Determinations are made in a timely manner based on the clinical urgency of the situation. HealthSpan complies with standards for timeliness of decisions and communication to providers and members as established by ERISA, URAC and other regulatory and accrediting bodies.

All denial decisions are based on medical necessity and are made by a licensed physician and are communicated verbally to the provider and administrator/insurer.