QUEST Integration – Pre-certification Timeliness Standards

HMSA’s Medical Management department reviews pre-certification requests (i.e., prior authorizations) and provides the physician with a determination of benefit coverage within the Department of Human Services, Med-QUEST Division established timeliness standards. The term pre-certification is the same as prior authorization.

Routine pre-certification requests will be reviewed and communicated to the physician within 14 calendar days of receiving the request. Determinations on pre-certifications that meet the following definition of “urgent” and that are clearly marked as “urgent” will be made within three calendar days of receiving the request. Scheduling issues are not factors for urgency.

An “urgent” request is defined as one that if processed within the time period applicable to non-urgent care could:

• Seriously jeopardize the member’s life, health or ability to regain maximum function, or
• In the opinion of the member’s treating physician would cause severe pain that cannot be managed without the care that is the subject of the pre-certification requested

If a request does not have sufficient information for a determination, providers will be notified and an additional 14 calendar days will be added to the review time. If the needed information is not received in a timely manner, the request will undergo medical director review with only the available information and could be subject to denial.

When requested services will not be covered, HMSA will send letters both to the requesting provider and member advising them of this determination with information on how to file an appeal if they wish to pursue the denial further.

Required Information for Pre-Certification Request

Pre-certification requests must include the applicable information listed below:

• Patient information: Name, address, date of birth, sex, HMSA QUEST member ID number and information about any other insurance coverage available (e.g., no-fault).
• Attending physician or provider information: Name, address, telephone number, fax number and HMSA provider number.
• Applicable clinical information about the proposed service or equipment:
  • History of present illness; primary and secondary diagnoses; proposed procedure, treatment or service; and the frequency of services or expected duration of treatment. For durable medical equipment, please include information about the make and model number of the equipment, cost itemization and the estimated length of time the item will be needed.
  • If services are to be performed at a higher-level setting than usual (e.g., surgery performed on an inpatient basis when it is normally performed in an ASC), please include the date of the proposed admission, date of the procedure, the reason the procedure is being performed at the higher-level setting, history of present illness and the expected length of the stay.
  • Some services (e.g., physical therapy beyond the maximum number of covered visits) require a treatment plan that includes goals, prognosis, and the number of days, services, or procedures requested and the frequency and expected duration of the services. If you are asking that the number of previously approved services be extended, please provide an updated treatment plan and clinical information supporting the need for an extension, including any changes in the patient’s diagnosis or prognosis.
  • If the pre-certification request is for a surgical procedure and the services of an assistant surgeon or surgical team will be needed, please indicate this information.
  • If you are asking HMSA to evaluate a new treatment or procedure for possible benefit coverage, please include clinical information supporting the appropriateness of the service, any available literature and current specialty assessment reports.
  • If the physician is requesting outpatient services (e.g., IV therapy) following an inpatient stay, he or she must include a copy of the discharge summary.
• Facility information: Name, address, telephone number, fax number and HMSA provider number. Also, include information about the type of facility (e.g., inpatient, outpatient, SNF).
• Contact: Please include the name and telephone number of a contact person familiar with the patient’s case to provide additional clinical information if needed.

Physician Reviewer

Determinations of HMSA criteria for benefit payment are decided by qualified medical professionals. Board-certified specialists are available for consultation when needed. HMSA physician reviewers are available to discuss medical management (MM) decisions with the treating physician.

If a physician would like to discuss a MM decision with a physician reviewer, he or she may call the MM department directly at 808-948-6464.

HMSA does not provide incentives to practitioners or individuals involved in MM decisions to deny or withhold care.

Payment Criteria

Pre-certification reviews the effectiveness of a request in treating a medical condition. Procedure codes are helpful in clearly describing the expected treatment. However, approval is not given for the procedure code itself because the actual procedure rendered may differ due to unexpected situations or conditions that may arise when the procedure or service is actually in progress.

Services that normally do not require pre-certification should be pre-certified if they are being provided for cosmetic reasons, non-medical conditions, or conditions that are not benefits. If such services are recommended due to unusual circumstances, pre-certification will determine whether it meets the criteria for payment under QUEST.

Dollar amounts provided with pre-certification requests for DME help to determine the appropriateness of purchase or rental options. However, payments will be based on the QUEST fee schedule for the item.

Revision History