Astiva Health Utilization Management Policy for Standard Organizational Determinations
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Governs Astiva Health's Utilization Management process for Standard Organizational Determinations on referral/prior authorization requests affecting Astiva Health members and delegated IPA/Medical Groups.
No material clinical or coverage changes in this revision.
Standard Organizational Determination Criteria
Standard Organizational Determination Criteria
Covered when ALL of the following organizational determination requirements and timelines are met:
ALL of the following
- Part C (referral) requests: determination no later than 14 calendar days from receipt of the request.
- Part B (drug) requests: determination and notification no later than 72 hours from receipt of the request; extensions permitted in specified circumstances (e.g., inability to obtain medical records).
ALL of the following
Request may be submitted by
- Member or member's authorized representative (with appropriate verification, e.g., AOR, POA, advance directive).
- Any provider who furnishes or intends to furnish services to the member.
- Legal court‑appointed representative of a deceased member.
- Requests may be submitted orally, in writing, or by fax.
ALL of the following
- If the Medical Director is unable to decide based on available information, consult a board‑certified specialist in the same or similar specialty to assist decision‑making.
- Responsibility for review, authorization, or denial is assigned to appropriate UM clinical staff.
ALL of the following
- If medical records cannot be obtained, Astiva Health may take an extension; after at least three documented good‑faith attempts to obtain records, lack of information may lead to denial for lack of established medical necessity.
Requested Service Codes & Documentation
| CPT | Requested service CPT codes should be included in clinical documentation. |
Provider Requirements, Timeframes, and Notifications
Submit a complete prior authorization package
Providers must submit a complete authorization request package that includes patient information (full name, date of birth, member ID), provider information (name, contact information, NPI, professional credentials if required), clinical documentation (short description and CPT codes for the requested service; clinical records supporting medical necessity including diagnostic findings such as X‑rays, photographs, or scans; a detailed treatment plan; relevant medical and dental history; any alternative treatment options considered) and supporting documentation (specialist consultations, second opinions, or relevant peer‑reviewed research articles).
- Patient Information: full name, DOB, identification number
- Provider Information: name, contact info, NPI, professional credentials (if required)
- Clinical Documentation: service description, CPT codes, diagnostic findings, treatment plan, relevant history
- Supporting Documentation: specialist consults, second opinions, relevant literature
Meet required determination timeframes
Astiva Health or delegated entities shall make Standard Organizational Determinations within 14 calendar days from receipt for Part C (referral) requests and must make a decision and notify for Part B drug requests within 72 hours of receipt; extensions are allowed for Part B drug requests or when medical records cannot be obtained (after three documented good‑faith attempts lack of records may lead to denial).
- Part C (referral) determinations: no later than 14 calendar days from receipt of request
- Part B drug determinations: decision and notification within 72 hours of receipt
- Extensions permitted for Part B drug requests or when medical records are unavailable; denial possible after ≥3 documented good‑faith attempts to obtain records
Notify member and submitting provider of the decision
Upon finalizing a referral, the member and the submitting provider must be notified either orally or in writing of the decision.
- Notification may be oral or written
- Both the member and the submitting provider must receive the decision
Obtain specialist consultation when needed
If the Medical Director is unable to make a determination based on the information provided, Astiva Health may consult a board‑certified specialist in the same or similar specialty to assist in decision‑making.
- Consultation should be with a board‑certified specialist in the same or similar specialty
Follow attachments and process flow (Part C Appeals)
Refer to the policy attachments for the Part C Appeals Process Flow (Attachment A) and the Standard Organizational Determinations Process (P&P #001); these attachments are included with the policy and outline the appeals process and related procedures.
- Attachment A: Part C Appeals Process Flow
- P&P #001: Standard Organizational Determinations Process (referenced in attachments list)
Key Definitions
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