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This is called an appeal of the adverse determination. A list of the Medicaid and CHIP covered services that require prior authorization may be found by visiting:. CHIP prior authorization approval and denial rates for the medical care or health-care services may be accessed by visiting:. Health-care providers are responsible for submitting prior authorization requests. Review the information below to learn more about which services may need prior authorization approval before the service is provided.
If you have any questions, please call Member Services Monday-Friday, 8 a. Prior authorization decisions are made using generally-accepted clinical practices, which include the special needs of each case that may require an exception to the standard. Clinical screening criteria are used to review the medical necessity of the requested service.
At least once a year, a review is completed to make sure all clinical reviewers follow the same process in clinical case reviews. Financial rewards are not offered to doctors, nurses or other clinical staff responsible for making a utilization review decision. In addition, utilization review policy and criteria do not allow decisions that may result in members not receiving all medically necessary services.
Physical and behavioral health emergencies, life threatening conditions and post-stabilization services do not require prior authorization. Except for emergency services, post-stabilization services, and services provided to you during an approved inpatient admission, all services from an out-of-network provider must be prior authorized. Claims for services from out-of-network providers that are not approved before the service is given may be denied.
Urgent or emergent admission to a hospital for an overnight stay does not require prior authorization. However, hospitals are required to provide notice of the admission within one business day of an admission. Your inpatient stay is reviewed during your inpatient stay, to make sure you are getting medically necessary and appropriate services in the hospital.
An example of an elective admission is a surgical service or procedure that requires an inpatient admission, but can be scheduled well in advance of the surgery or procedure. Your provider is responsible to request the prior authorization for the admission. Some medications may require prior authorization and may have clinical prior authorization edits or other limitations related to federal Food and Drug Administration FDA recommendations.
This is to make sure they are safe and effective. Other medically necessary pharmacy services or products are covered if included on the VDP approved list. In certain cases, you may be given a hour emergency supply of a drug that requires prior authorization. Family planning, emergency room, post-stabilization services, and table top x-rays never require prior authorization. Prior authorization requests may be submitted by fax, phone or the Secure Provider Web Portal and should include all necessary clinical information.
Urgent requests for prior authorization should be called in as soon as the need is identified. Iowa Total Care will process most standard prior authorization requests within five days. If we need additional clinical information or the request needs to be reviewed by a Medical Director, additional days may be needed to make a determination. Detailed information on prior authorization determination timelines is included in the Provider Manual.
CST excluding holidays. After normal business hours, we have an after hours service available to answer questions and intake requests for prior authorization.
Failure to obtain the required prior authorization for a service may result in denied claims.
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