Utilization Management Process
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Defines CareSource Georgia's utilization management processes for providers, including authorization, notifications, inpatient review, prior authorization (standard and urgent), administrative and post-service review procedures; applies to CareSource providers interacting with CareSource Georgia processes.
No material clinical or coverage changes in this revision.
Utilization Management Coverage Criteria
Utilization management coverage criteria
Covered when ALL of the following processes and review conditions are met:
ALL of the following
- Staff review inpatient length of stay against Milliman Clinical Guidelines (MCG) clinical criteria.
Outcome
- If MCG criteria are met: a CareSource clinical reviewer may approve up to the maximum MCG length of stay; facility notified of approval and number of days via fax or portal notification.
- If MCG criteria are not met: CareSource medical director will review the request and make a determination; facility notified of decision via fax or portal notification.
ALL of the following
- Provider must submit up-to-date clinical documentation, including potential discharge needs, to substantiate need for additional inpatient days.
- Staff reviews documentation against MCG; if criteria met, days granted are determined by member's clinical status and MCG; if not met, medical director review occurs.
- Once determination is made, facility is notified of decision and number of days (if approved) via fax or portal notification.
ALL of the following
- CareSource will review requests received within 30 calendar days of the date of service, or for retrospective enrollment or specific contract terms; decision rendered within 30 calendar days of receiving all information reasonably necessary to make a determination.
- Requests submitted greater than 30 calendar days after the date of service or retrospective enrollment will be administratively denied.
- If a claim is submitted prior to a retrospective/post-service determination, the claim will be denied as pending with no authorization on file.
ALL of the following
- Administrative denials may be issued when providers fail to adhere to CareSource authorization/notification requirements (examples include late notification, failure to obtain prior authorization, missing required forms, out-of-network services without prior authorization, duplicative services, lack of eligibility, or exhaustion of benefits).
- Peer-to-peer discussions are not offered for administrative denials based solely on administrative issues.
Coding and Service Limits
| Providers should use the Procedure Code Lookup Tool to determine whether a service code requires prior authorization. |
Provider Submission, Notification, and Authorization Requirements
Submission methods — portal or fax required; email no longer accepted
Effective July 2, 2021 CareSource's Utilization Management department will no longer accept emailed requests for authorization. Providers must submit authorization requests using the CareSource Provider Portal or by fax (use the appropriate fax number for the plan/service). The Provider Portal supports real-time determinations via Cite Auto Auth.
- Do not send authorization requests via email after July 2, 2021.
- Use the CareSource Provider Portal for submissions and real-time determinations (Cite Auto Auth).
- If using fax, select the correct fax number for the plan and service from the listed fax numbers.
Notify CareSource of emergent admissions within 1 business day
Providers must notify CareSource of an emergent inpatient admission within one (1) business day of the admission.
- Send notification via the CareSource Provider Portal or fax per the submission instructions.
Administrative denials — failure to follow authorization/notification rules
CareSource may issue an administrative denial when providers fail to follow authorization or notification requirements; examples include late admission notification, failure to obtain prior authorization, missing required state forms, rendering non-covered or out-of-network services without authorization, duplicative services, lack of member eligibility, or exhaustion of benefits.
- Administrative denials are non-medical decisions and peer-to-peer is not available for administrative denials.
- Failure to adhere to Provider Manual policies and procedures can result in denial or delayed reimbursement.
Prior authorization not required for emergency, post-stabilization, and urgent care
Emergency services, post-stabilization services, and urgent care services do not require prior authorization and are exempt from prior authorization requirements.
- Neither the member nor the provider is required to obtain prior authorization for emergency services.
- Post-stabilization and urgent care services are also exempt from prior authorization.
Key Definitions
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