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Referrals and Prior Authorization

The HealthPlus Medical Management Program was designed to support providers in delivering prompt, efficient and timely healthcare services, while also ensuring that members receive the “right care, in the right location and at the right time”. The program employs a comprehensive approach toward providing medical and behavioral health services by integrating utilization and case management activities.

The following activities focus upon medical and behavioral health services:

  • Primary care physician to specialist referral management
  • Prior authorization of select inpatient, ambulatory and outpatient services (medical, pharmacy, and behavioral health services);
  • Inpatient admission and concurrent review (medical and behavioral health);
  • Post-service review (medical and behavioral health services);
  • Behavioral health, chronic disease and complex case management;
  • Care Counseling potential gaps in care/quality of care identification;
  • Provider/practitioner appeal process;
  • Inter-rater reliability testing for utilization staff and physicians;
  • Physician and member satisfaction with the Medical Management Program;
  • Continuity and coordination of care;
  • Delegated medical management oversight;
  • Analysis of utilization data for trends in over- and under-utilization;
  • End of Life and Advance Illness management;
  • Consideration of cultural and linguistic needs of members, and
  • Benefit administration and interpretation, including new technology assessments and determinations regarding experimental and investigational treatments.

On-call clinical staff is available after normal business hours on weekdays,weekends and holidays (24 hours) to perform reviews and/or respond to utilization, referral or pharmacy authorization inquiries from members, providers and practitioners. HealthPlus’ on-call process, for utilization, referrals and pharmacy services is administered through the use of an answering service with direct access (warm transfer) to clinical on-call staff to assist the caller with their inquiry. On-call clinical staff will make medical necessity determinations within one hour of their call, for hospitals who have a signed Hospital Access Agreement with Michigan's Department of Health Services. For non-urgent issues, a message may be left after hours, weekends or holidays with the answering service and their call will be returned by HealthPlus staff the next business day.

Behavioral health clinical staff is available to physicians, providers and members 24 hours a day, seven days a week.

Referrals

Referrals are required when a PCP determines it necessary to send a HMO* member, to a specialist for a consultation and/or a consultation with additional visits or procedures to be performed. PCP’s must refer all non-PPO members to a contracted HealthPlus provider, unless the necessary services are not available through a contracted provider, at which time the PCP office can request an out-of-plan referral, allowing the member to seek services from an non-contracted provider.

*Point of Service (POS), PPO and Medicare Supplemental HMO members are not required to obtain a referral, prior to seeking care from a specialist; however a POS member may choose to request a referral, due to the tiering of their benefit structure(s).

HealthPlus has two types of referral:

  • Open Referral  
    • Eligible referrals will be active for no less than 60 days and no greater than 365 days, with unlimited visits during that timeframe.
    • allows the PCP, specialist and member greater flexibility in managing the patient’s healthcare needs
    • All current open referrals will now have an end date of Dec. 31. If any of your patients have an open referral, they will be required to obtain a new authorization with HAP beginning Jan. 1, 2017. HealthPlus and HAP are committed to ensuring that your patients’ care is not interrupted and will work closely with you during the transition. If you have questions regarding the transition of referrals to HAP, please call our provider services team at (855) 211-7766.
  • Limited Referral
    • Date range and number of visits are establish by the PCP
    • are applicable to ONLY certain specialties and plans
    • services that require medical necessity review by the Plan Medical Director (i.e. cosmetic services or out of plan referrals)

The following represents services and/or Plans that do not require a referral:  

  • Behavioral Health Services: for more information about HealthPlus behavioral health benefits, please contact the Behavioral Health Department at (800) 555-5025.
  • Routine preventative OB/GYN services
  • Rendering of urgent and emergent services
  • All PPO specialty care
Referral requirements for 14 specialities were eliminated in September 2012 for the HealthPlus Commercial  HMO and Medicare Advantage HMO. Those specialists are:
  • Critical Care Specialist
  • Gastroenterology
  • Gynecology/Oncology
  • Hematology/Oncology
  • Hospitalist
  • Maternal & Fetal Medicine
  • Nephrology
  • Neurology
  • Oncology
  • Optometry
  • Perinatology
  • Pulmonary Medicine
  • Radiation Oncology
  • Rheumatology
All other specialty care will continue to adhere to HealthPlus current referral requirements. HealthPlus recognizes many in-plan physicians are affiliated witha  physician-hospital organization (PHO) and as such, there acould be additional referral requirements you may need to follow. 

Submission of Medical and Surgical Referrals:

Referrals may be submitted electronically via the web or by fax. Referrals for patients who have an urgent healthcare need may be requested via phone, directly to the Referral department at: 800-733-6360 or 800-942-5374.

Special Referral Program(s)

Physical Medicine & Rehabilitation Program:  

  • *Members are required to have an exam by a physical medicine and rehabilitation (PM&R) specialist, prior to seeking care from a surgeon for non-urgent neck or back pain.
  • Applies to all lines of business except PPO *In the presence of urgent surgical needs , the following “red flag” criteria MUST be submitted to the Referral Department, for a member to be exempted from the PM&R exam requirement:
    • Cauda Equina Syndrome
      • Urinary retention or incontinence
      • Loss of anal sphincter tone or fecal incontinence
      • Saddle anesthesia (about the anus perineum and genitals)
    • Severe neurologic compromise
      • Sudden or progressive motor weakness or sensory loss in one or more limbs.
    • Spine trauma resulting in fracture
    • Evidence of spinal infection, tumor, or malignancy.

    MQIC Guidelines for the Management of Actue Low Back Pain are available for review.

    Prior Authorization

    There are some covered services that require the prior approval of the Plan Medical Director, prior to services being rendered.

    The following procedures are not covered unless they are determined to be medically necessary and authorized prior to rendering of the service by a HealthPlus Plan Medical Director. Supporting documentation must be provided with the prior authorization request for the following:

    • Non-emergent Ambulance Transfers
    • All cosmetic services
    • Treatment for varicose veins
    • Behavioral Health Services
    • Substance abuse services
    • Infertility services  
    • Elective in-patient admissions
    • Elective skilled nursing, long term care (LTC) and rehabilitation facility admission  
    • Oral surgery and related services
    • Organ and tissue transplants
    • Ophthalmological services for diagnoses of pre-glaucoma, or pre-cataracts
    • Weight management services (Medical Interventions)
    • Uvulopalatopharyngoplasty
    • Ductal lavage
    • External counterpulsation
    • Autologous chondrocyte transplant
    • Left ventricular assistive devices
    • Uterine artery embolization
    • Chiropractic services
    • PT, OT, ST Therapies
    • Specialist services (e.g., genetic testing, , infertility, capsule endoscopy, transplantation, adult sterilization, autologous chondrocyte transplant, termination of pregnancy, external counter pulsation, biofeedback, left ventricular device, vagus nervestimulation)
    • Certain medications
    • High-tech imaging and nuclear testing through CareCore  
    • Durable medical equipment
      • power-operated vehicles (POV)
      • items that might be considered “deluxe”
      • unlisted codes
      • items over $3,000 or per claim
      • CPAP and BIPAP  
      • Bone stimulators
       

    If you have questions related to the HealthPlus Referral or Prior Authorization processes, please contact the Referral Department at (800) 733-6360 or (800) 942-5974, or by email at Referrals1@healthplus.org.  

    Utilization Management

    The Utilization Management (UM) department is staffed and managed by licensed, registered nurses who perform inpatient UM activities which include; inpatient acute care admission review, on-going acute care concurrent review, discharge planning and continuity of care initiatives, in addition to reviews for long-term extended care, and skilled nursing care.The utilization review nurses are the primary contacts with the hospitals in addition to interacting with other health care professionals in support of successfully transitioning a member to another setting upon discharge from an acute care facility . The UM staff reviews provider-initiated appeals and prepares them for medical director review for medical necessity determination. In addition, UM also assists in data collection related to HEDIS ® Effectiveness of Care Measures and in the coordination of care with disease and case management program staff.

    Inpatient Admission Review and Certification  

    All acute care facilities are required to notify HealthPlus of any inpatient admissions. Behavioral health inpatient, partial hospitalization, intensive outpatient admissions and skilled nursing facility admissions must be authorized before the admission. PPO members are required to notify HealthPlus five days prior to a scheduled admission or within 24 hours of an urgent/emergent admission.

    • Reviews are performed by a utilization reviewer and occurs within 24 hours of admission or the first working day after the admission in coordination with the PCP and/or attending physician.
    • Failure to receive information needed to review a stay, will result in an administrative adverse determination regarding all or part of the admission.
    • Members who receive care at an out-of-network facility and are in stable condition and deemed appropriate for transportation, by the attending physician, may be transferred to a participating facility for continued treatment. Members not deemed to be in stable condition and require continued care, are followed via telephone with the facility.

    Re-Admission Guidelines:

    Application of Medical Necessity Criteria:

    • Make determinations regarding medical necessity/appropriateness for medical, behavioral and pharmaceutical care.
    • Medical management and pharmacy staff primarily make use of nationally accepted, objective, evidence-based guidelines or criteria appropriate to the service under review.
      • In the absence of national guidelines/criteria, HealthPlus may develop internal, evidence-based guidelines with the involvement of appropriate professionals. These criteria are reviewed annually by practitioners with professional knowledge or clinical expertise in the area being reviewed and have an opportunity to give advice or comment during the development, adoption and review of these guidelines/criteria.
    • Criteria for Observation and Extended Recovery Services
      • For medical admissions, after treatment, monitoring or stabilization has occurred, InterQual criteria or other approved medical necessity criteria (i.e. HealthPlus Annual authorization requirement notification of InterQual exceptions and Benefit Interpretation guidelines) will be applied, to determine if an inpatient admission is appropriate. For this reason HealthPlus may request and obtain clinical data, within the first 23 hours of arrival to evaluate the appropriateness (severity of illness/intensity of service) of the admission. If, after “a significant period of treatment or monitoring” the member’s condition has improved/resolved, an inpatient admission may be denied. A HPM Medical Director will review the information received and if the member does not meet inpatient criteria, the inpatient request will be denied. The provider may then choose to treat the member in the Inpatient setting and appeal HealthPlus’ decision, or the provider may choose to treat the member in the lesser setting of observation. Observation services do not require an authorization, and are reimbursed consistent with a member’s Certificate of Coverage.
      • For surgical admissions, HealthPlus may request and obtain clinical data within the first 23 hours post the surgical event to evaluate the appropriateness (severity of illness/intensity of service) of the admission. A HPM Medical Director will review the information received and if the member does not meet inpatient criteria, the inpatient request will be denied. The provider may then choose to treat the member in the inpatient setting and appeal HealthPlus’ decision or the provider may choose to treat the member in the lesser setting of outpatient with extended recovery. Extended recovery services do not require an authorization, and are reimbursed consistent with a member’s Certificate of Coverage.
      For a full version of the HealthPlus policy and procedure related to medical necessity determinations, please call HealthPlus at (989) 797-4043.
    • All benefit determinations are made in accordance with the benefit design of the applicable member’s contract.
    • The utilization reviewer verifies eligibility, availability of benefits, consults with the treating physician, and gathers other relevant clinical information, including but not limited to: history of presenting problem, patient treatment plans and goals, individual circumstances (i.e. age, co-morbidities, complications, psychosocial situation, and home environment), second opinion information, if appropriate, etc.

    No Utilization Incentives:

    HealthPlus utilization management decision-making is based only on appropriateness of care and service and the existence of coverage. HealthPlus does not specifically reward any person involved in the utilization review process for issuing denials. HealthPlus does not compensate any person with responsibility for the utilization management program in a manner which would motivate them to make inappropriate review decisions.

    Utilization Management Decisions:

    HealthPlus makes decision and notification activities in a consistent and timely manner to minimize disruption in the provision of health care for its members. Decision-making at HealthPlus is based only on appropriateness of care, service and is made in compliance with state, federal and accrediting agency regulations. All benefit determinations are made in accordance with the benefit design of the applicable subscriber contract.

    Adverse medical necessity determinations can only be made by a HealthPlus physician reviewer. When HealthPlus utilization staff or pharmacy staff is unable to approve proposed or continued care for reimbursement as requested by a practitioner, the appropriate medical director reviews the request and any available clinical information. Based on the medical director’s review, the utilization or pharmacy staff may issue an adverse determination to the member, practitioner/provider and the PCP. The notification includes the rationale for the denial and an explanation of the process for appeal.

    Practitioners may discuss any utilization decision with a HealthPlus physician reviewer or appropriate behavioral health reviewer.

    HealthPlus notifies practitioners of any utilization management adverse determination. The adverse determination notice includes information on how to contact a physician reviewer or appropriate behavioral health reviewer by telephone to discuss the decision. A copy of the medical necessity criteria, guideline or benefit provision used to make the decision is available upon request.

    If you have additional questions related to Utilization Management services, please contact 810- 230-2029 or 989-797-4000.

    Medical Review & Appeal

    Concurrent Review:

    Concurrent review is the process of continual reassessment of: the medical necessity and appropriateness of acute medical or behavioral inpatient, partial hospitalization and intensive outpatient care, during a facility admission.

    • The review identifies case management needs, quality of care issues and assistance in arranging timely discharge.
    • Out-of-area admissions require an approved referral and are reviewed via telephone.
    • Concurrent review is conducted by the utilization reviewers and is performed each business day, with decisions rendered and appropriate parties notified of length of stay recommendations on the same day. Failure to receive information needed to review a stay will result in an administrative adverse determination regarding all or part of the admission.
    • All questionable cases that do not satisfy the specified guidelines are directed to the Plan Medical Director for review and determination.

    Post-Service Review:

    Post-Service review is performed for the following reasons:

    • To evaluate the appropriateness of member and practitioner/provider inpatient and outpatient utilization patterns, as well as to identify any quality of care concerns.
    • To evaluate cases where circumstances prevented the member, facility or provider from seeking authorization of care.
    • To match the authorized services to charges received.

    When a service requires clinical review, HealthPlus clinical staff applies the applicable criteria and/or member’s benefit. If all clinical documentation is provided at the time of the request, HealthPlus renders a decision and provides written notification to the member, PCP and attending provider within 30 days of the receipt. If the clinical staff is unable to approve the request based on medical necessity, the clinical information is forwarded to a plan medical director for review. Denial notifications include the reason for denial, a description of how to file an appeal and the availability of a medical director to discuss the individual merits of the case with the practitioner.

    Appeals:

    HealthPlus is committed to a systematic approach for seeking resolutions in situations where payment for services is not authorized. Whenever concerns or issues cannot be resolved through routine inquiry procedures, the appeal process may be initiated by the provider.

    A routine inquiry is one in which the provider seeks and receives clarification about the decision made by HealthPlus. An appeal is initiated when a provider requests, in writing and within 60 days of the adverse determination, the desire to have the decision reconsidered. A cover letter requesting the appeal (or reconsideration) along with supporting documentation indicating the reason for the appeal must be submitted. HealthPlus will respond to the provider via letter, with the results of the reconsideration, within 45 days from the date of the receipt of the supporting documentation.

    To submit an appeal complete and mail the following to HealthPlus:

    • A cover letter requesting appeal (or reconsideration)
    • Supporting documentation indicating the reason for the appeal

    Mail to:
    HealthPlus
    PO Box 1700
    Flint, MI 48501-1700
    ATTN: Utilization Review or Referral Department

    Confidentiality:

    The medical management process deals with sensitive information concerning the healthcare services delivered to members by providers. The documents created and reviewed as a part of the utilization management process are confidential and privileged information and are maintained in compliance with appropriate federal and state law concerning the confidentiality of medical records. All employees and consultants retained by HealthPlus must maintain a standard of ethics and confidentiality regarding both member information and proprietary information. To ensure the appropriate handling of confidential information, all employees are required to sign a confidentiality statement upon employment, and annually thereafter. Ongoing monitoring is performed to ensure compliance with confidentiality policies. Employees also are required to receive HIPAA Privacy and Security Standards training within a reasonable time of employment and thereafter as policies, procedures or the law changes. Similarly, HealthPlus requires clinical and administrative service organizations which HealthPlus contracts with to sign a Business Associate or confidentiality agreement.

    Additional Resources: