Procedural Guidelines

The following outlines the process providers take to submit requests for precertification of certain services, genetic and genomic tests and specialty drugs administered in an inpatient, outpatient or provider's office setting.

Confirm Requirements

Confirm if precertification is required by reviewing the list of services that require precertification.

How to Submit

Obtain precertification as follows:

Services requiring prior authorization through AmeriHealth Administrators Medical Management

• See the list of services that require precertification.
• Precertification for Behavioral Health and Substance Use Disorder conditions are done in conjunction with Magellan HealthCare.
• Call the phone number listed on the member/participant's ID card to reach the utilization review department.

What You Need

• Providers should complete this form, and be prepared to provide the following information for the request:
• Patient's medical or behavioral health condition
• Proposed treatment plan
• Date of service, estimated length of stay (if the patient is being admitted)
• Patient ID and name/date of birth
• Place of treatment
• Provider NPI, name and address
• Diagnosis code(s)
• Procedure code(s) (if applicable)

Renewal of an existing prior authorization can be requested up to 60 days before the expiration of the existing prior authorization.

Approval Process

• After the request is submitted, the service or drug is reviewed to determine if it:
• is covered by the health plan, and
• meets the health plan's definition of "medically necessary."

The prior authorization is then completed, and the results are sent to the provider.

If you have questions regarding the response, contact the utilization review department at AmeriHealth Administrators.

Important Information if You Choose to Appeal

The enrollee or someone acting on the enrollee's behalf and the provider of record have the right to appeal the adverse determination (denial) orally or in writing. A physician who has not previously reviewed the case will make the appeal decision. The appealing party must send us the appeal no later than 180 days after the date of this letter. At any time, you have the opportunity to submit additional written comments, documents, and/or other information pertaining to your claim for review. At your request, we will provide access to, and copies of, all relevant documents, records, and other information at any time to your or your authorized representative free of charge.

For medical necessity issues, should you desire more information about the decision and/ or a free copy of the description of, or the source of, the screening criteria that we utilized in making the determination, please send a written request including the reference number found at the top of the determination letter to "Clinical Rationale" at the address provided below.

Medical Necessity Appeal

A URA's formal process by which an enrollee, an individual acting on behalf of an enrollee, or an enrollee's provider of record may request reconsideration of an adverse determination based upon medical necessity or, decisions that were made based upon identification of treatment as cosmetic or experimental/investigative. Appeal decisions are made by physicians in the same profession and in a similar specialty as typically manages the medical condition, procedure, or treatment and is neither the physician who has previously reviewed the case nor a subordinate of such physician.

Administrative (Complaint)

Complaint - An oral or written expression of dissatisfaction with a URA concerning the URA's process in conducting a utilization review.

At any time during the appeal process, you or an individual acting on behalf of the enrollee may request the aid of an employee of AHA in preparing or presenting your appeal at no charge. This employee has not participated in the previous decision to deny coverage for the issues in dispute and is not a subordinate of anyone who previously reviewed the file. If you would like assistance in preparing your appeal, please call the number listed below.

To file an appeal of this determination, call, write or fax a request to:

Internal Appeals - Standard and Expedited

Standard Appeals

Medical Necessity (Pre-service or Post - service)

• Preservice - An appeal for benefits that, under the terms of this Contract, must be pre-certified or preapproved before medical care is obtained in order for coverage to be available.
• You have one (1) level of internal standard appeal of an adverse determination involving non-urgent pre-service care. Standard appeals are resolved within Thirty (30) days of receipt of the appeal.

• Post-service (retrospective) - An appeal concerning claims that have been received for services that the Covered Person has already obtained.
• You have one (1) level of internal standard appeal of an adverse determination involving non- urgent post-service care. Standard appeals are resolved within thirty (30) days of receipt of the appeal. We may also extend this deadline once for a period not to exceed fifteen (15) days.

Specialty Appeal

The provider of record may request a specialty appeal, which requests that a specific type of specialty provider review the case. The provider must request this type of appeal within 10 working days from the date the appeal was requested or denied. We will complete the specialty appeal and send our written decision to the enrollee or the person acting on the enrollee's behalf and the provider within 15 working days of receipt of the request for the specialty appeal.

Urgent Care / Expedited Appeals

An expedited appeal is available for a denial of emergency care, a denial of continued hospitalization, or a denial of another service if the requesting health care provider includes a written statement with supporting documentation that the service is necessary to treat a life-threatening condition or prevent serious harm to the patient. An expedited appeal is also available for denials of prescription drugs and intravenous infusions for which the enrollee is currently receiving benefits and for denied step therapy protocol exception requests.

An Urgent Expedited Appeal is any appeal for medical care or treatment with respect to which the application of the time periods for making non-urgent determinations could seriously jeopardize the life or health of the Covered Person or the ability of the Covered Person to regain maximum function, or in the opinion of a physician with knowledge of the Covered Person's medical condition, would subject the Covered Person to severe pain that cannot be adequately managed without the care or treatment that is the subject of the appeal.

Your one (1) level of Internal Expedited Appeal is completed based on the immediacy of the medical or dental condition, procedure, or treatment, but may in no event exceed one working day from the date all information necessary to complete the appeal is received. An expedited appeal is also available for denials of prescription drugs and intravenous infusions for which the enrollee is currently receiving benefits. Review is completed by a health care provider who has not previously reviewed the case and is of the same or a similar specialty as the health care provider who would typically manage the medical or dental condition, procedure, or treatment including prescription drugs and intravenous infusions under review in the appeal. We may provide the determination by telephone or electronic transmission, but written notification is provided within three (3) business days of the initial telephonic or electronic notification.

Note: If you believe your situation is urgent, you may request an Expedited External Review. You have the right to file an Expedited External Review facilitated by AmeriHealth Administrators. Please see below for more information about the independent review.

Life-Threatening Conditions: "Life threatening" means a disease or condition from which the likelihood of death is probable unless the course of the disease is interrupted.
If the patient has a life-threatening condition or receives a denial for prescription drugs or intravenous infusions for which they are currently receiving benefits, the patient, or someone acting on the patient's behalf, and the provider of record can request an immediate review by an independent review organization (IRO) and is not required to follow our internal appeal procedures. See below for more information about the independent review.

Acquired Brain Injury Appeal:

Appeal requests for acquired brain injury are completed no later than three (3) business days after the date on which an individual requests utilization review or requests an extension of coverage based on medical necessity or appropriateness. Notification of the determination is made through a direct telephone contact to the individual making the request. Written notification will be provided within 30 calendar days of appeal request.

• Note: Acquired Brain Injury Appeal does not apply to a determination made for coverage under a small employer health benefit plan.

Exhaustion of Internal Appeals:

We will not require exhaustion of our internal appeals process if: (a) we fail to meet our internal appeal process timelines, or (b) the claimant with an urgent care situation files an external review before exhausting our internal appeal process, or (c) we decide to waive the appeal process requirements.

Information About External Review:

You have only one (1) level of External Review with an IRO. An External Review process is available for any adverse benefit determination that involves medical judgment as determined by the external reviewer and for rescissions of coverage.

External Review Options

SELECT:

THIS OPTION HAS NO FILING DEADLINE.

• Grandfathered plans and disease-specific insurance policies under the jurisdiction of the Texas IRO process.

Texas Independent Review: If we denied the appeal (continue to deny the services or treatment described above), the enrollee or someone acting on the enrollee’s behalf and the provider of record have the right to request a review by an IRO. The IRO does not have an affiliation with your payor (insurance company or health plan), your health care providers, or the URA.

To request the independent review, fill out TDI form LHL009 and return it to AmeriHealth Administrators, Attn: Appeals Department, PO Box 21545, Eagan, MN 55121. Fax: 215-761-0956.

The patient, parent, or the patient's legal guardian must sign the consent to release medical information to the IRO (included as part of the IRO form).

OR SELECT:

THIS OPTION MUST BE COMPLETED WITHIN 180 DAYS FROM THE DATE YOUR INSURER SENT YOU A FINAL DECISION DENYING YOUR SERVICES.

• HHS-administered Federal external review process for non-grandfathered plans and policies subject to the ACA.

HHS-administered Federal External Review: For a standard IRO review, you, or someone you name to act for you may file a request for external review within four months of receiving this letter. If you would like to have another person make an external review request on your behalf, both you and your authorized representative will need to complete and sign the HHS Federal External Review Process Appointment of Representative Form, which can be found in the links provided below:

HHS - Administered Federal External Review Request Form
HHS Federal External Review Process Appointment of Representative Form

If you believe your situation is urgent, you may request an expedited external review by calling the number below immediately to begin the process. If you want to send more information to include in the review, you can send it with your request. You may use an HHS Federal External Review Request Form to provide this and other additional information.

When MAXIMUS Federal Services receives your request, they will notify us, and we'll send them all of the case information for review. If you send them any more information, they'll share it with us. We may change our decision. If not, the IRO will continue the review. You'll receive a letter with their decision. If MAXIMUS Federal Services decides to overturn our decision, we will provide coverage or payment for your health care item or service.

Complaint Procedures:

• You can send a complaint to us (the URA): Enrollees individuals acting on behalf of enrollees, and health care providers may file a written or oral complaint about our utilization review process or procedures. Use the telephone numbers and address referenced above to file your oral or written complaint. We will respond to your complaint in writing within 30 days.
• Complaints to the Texas Department of Insurance (TDI): A complainant also has the right to file a complaint with TDI by contacting TDI at the address, telephone numbers, or website below.

If your health plan is subject to the requirements of the Employee Retirement Income Security Act (ERISA), following your appeal you may have the right to bring civil action under Section 502(a) of the Act. For questions about your rights, this notice, or for assistance, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). Additionally, a consumer assistance program may be able to assist you at:

If your plan fails to "strictly adhere" to the internal appeals process, you may initiate an external review or file appropriate legal action under state law or ERISA unless:

• Violation was de minimis (minimal).
• Did not cause (or likely to cause) prejudice or harm to the claimant.
• Was for good cause or due to matters beyond the control of the insurer/plan.
• In the context of a good faith exchange of information with the claimant.
• Not part of a pattern or practice of violations.

AmeriHealth Administrators has free telephone language-line services and TTY/TDD for the deaf or hearing impaired. If you or a member you know has difficulty communicating because of an inability to speak or understand English and needs language assistance, call the Customer Experience number on your ID Card (for the hearing impaired: TTY/TDD 711). Follow the prompts or wait to speak with a Customer Experience Advocate.

Related Resources

GeoBlue Medical Policies

Precertification Data for Jan-Dec 2022.pdf

Precertification Data for Jan-Dec 2023.pdf

AmeriHealth Administrators is an independent medical benefits management company that provides utilization management services for GeoBlue.

GeoBlue and 4 Ever Life Insurance Company make no endorsement, representations or warranties regarding any products or services offered by AmeriHealth Administrators or Magellan Healthcare. The vendors are solely responsible for the products or services they offer. If you have any questions regarding any of the products or services they offer, you should contact the vendor(s) directly.

Please note that checking eligibility and benefits, and/or the fact that a service or treatment has been prior authorized or predetermined for benefits is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member's eligibility, and the terms of the member's certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on the member's ID card.