We're expanding pre-authorization (PA) reviews to help provide members better access to high-value care

May 30, 2023

We're committed to providing our members access to high-quality care at the lowest price. In support of this commitment, we regularly evaluate and update our Utilization Management (UM) policies to ensure members are receiving the care they need in the setting that's clinically appropriate and most cost-effective.

Effective July 1, 2023, we're implementing new site-of-service pre-authorization (PA) reviews for select hospital outpatient procedures among the following specialties:

• Digestive
• Genital systems (male and female)
• Hematology and lymphology
• Integumentary
• Nervous system
• Ophthalmology
• Respiratory
• Urology

Under site-of-service PA review, when a procedure can be performed safely and effectively outside a hospital outpatient setting, the member and provider will receive a coverage denial letter advising that hospital outpatient treatment isn't clinically appropriate. Site-of-service reviews are done solely to evaluate the clinical appropriateness of performing a procedure at a requested treatment facility; they're separate from any medical PA requirements to determine medical necessity.

As with other PA programs, the obligation to secure PA for services rendered in hospital outpatient settings rests with providers. (There's no action for the member to take, although members do receive PA approval or denial notifications.) Providers are advised to check with our PA lists and can request PA using the Availity Essentials E-Auth application or via fax.

The following factors, among others, are considered when determining the appropriate site of service:

• Member's health status
• Facility and geographic availability
• Specialty requirements
• Provider privileges

Site-of-service PA reviews will be implemented for all commercial group, Individual and Medicare Advantage plans. The list of procedure codes affected can be found here. We notified providers about site-of-service PA reviews in our April 1, 2023, provider newsletter, The Connection℠.

Site-of-service PA reviews are increasing in frequency as payers and public agencies seek to rein in provider cost increases. In 2022, we began implementing site-of-service reviews for select colonoscopy and endoscopy services. In April, we announced site-of-service reviews for certain joint care procedures effective June 1.

Effective July 1, 2023, Chartcheck may require providers to submit medical records with their preauthorization request. This helps ensure proposed treatment meets current standards of practice and contains costs by avoiding inappropriate treatment. ChartCheck applies to certain radiology services such as:

• MRI Brain for headaches
• CT Chest for pulmonary nodules or abnormal imaging
• MRI Lower Extremity for tendon injury
• CT Sinus for sinusitis
• MRI Lumbar Spine for abnormal imaging

Questions? Contact your account representative.