Utilization Management Program Description
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Describes Western Health Advantage's Utilization Management (UM) program structure, delegation, and functions governing UM decisions for WHA members and network providers.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
UM program-level coverage criteria
Covered when ALL of the following program-level expectations are met:
From purpose and scope statements
Delegation with retained responsibilities
Monitoring and review responsibilities
Medical Necessity Decision Process
Coverage and medical necessity determinations follow these program rules and processes:
From section 4.0
Medical Necessity Authorization Criteria
Covered when decisions meet WHA-approved medical necessity criteria and are made by appropriate reviewers
Criteria and citation are included in notification letters when denials occur
Timeliness Criteria
Decisions must meet DMHC timeliness standards and WHA goals
Concurrent review and other specific timeframes described in policy
Program coverage criteria and operational requirements
Processes and criteria for denials, appeals, authorization, discharge planning, continuity of care, and case management:
From Denials section
From Appeals section
From Appeals and ARM sections
From Prior Authorization section
From Discharge Planning section
From CoC section
From CM/CCM section
Covered CCM and Continuity Services
Covered when WHA or delegated entities provide the following CCM and continuity services:
From Continuity of Care section
From CCM Introduction and Data/Criteria sections
From CCM program requirements and Addendum
From Second Opinions section
Eligibility and Enrollment
Members are appropriate for CCM when ALL of the following general conditions are met:
From program overview
Includes proactive population analytics and direct referrals
CM explains program and documents acceptance/declination
Covered CCM Services
Covered services and program features include:
Complex CM includes long-term intensive coordination; routine CM includes navigation and education
Ensures continuity of care across vendors
WHA retains responsibility for specific Utilization Management functions and does not delegate them to contracted medical groups/IPAs. These retained functions include out-of-network urgent care and emergency services, related hospital admissions, non-network second opinions, transplants, appeals, clinical trials, specialty pharmacy, and experimental treatment requests.
Authorization decisions that do not involve a medical necessity determination are governed by the member's purchased health plan options. The specifics for each member’s plan — including covered benefits, copayment summaries and exclusions — are described in the member's Evidence of Coverage (EOC) & Disclosure documents and are the basis for any coverage-based authorization decision.
When a referral is denied because the service is not a covered benefit, WHA cites the appropriate exclusion language from the member’s Combined Evidence of Coverage and Disclosure Form in notification letters so the member and provider clearly understand the reason for the adverse decision.
WHA's program description states that the organization does not conduct onsite facility reviews. Denial and modification decisions are instead made by appropriately qualified clinical reviewers using medical records and established clinical criteria, with written notification and appeal rights provided to the member and provider.
Certain behavioral health benefits for defined employee groups have been carved out to other vendors. For example, some employer-provided behavioral health benefits have been carved out to OptumHealth, and Magellan (HAI-CA) handles behavioral health triage, referral and network access under its MBHO arrangement.
No additional explicit exclusions are stated in the referenced sections of the document beyond those already identified elsewhere in the policy. The policy indicates targeted populations for CCM outreach and notes services are available to members at no cost, but does not list other exclusion categories in these chunks.
Adverse decisions based on medical necessity (denials or modifications) are documented and must be issued by an appropriately qualified physician or pharmacist reviewer. WHA requires that denial/modification decisions be communicated in writing with clear reasons, cite the specific clinical criteria used to make the decision, identify the reviewer or review body, and include instructions for internal appeal and external grievance options.
Within the provided chunks there are no explicit lists of conditions or services labeled as 'not medically necessary.' The document describes the process for making and documenting medical necessity determinations but does not enumerate specific 'not medically necessary' exclusions in these sections.
Coding and Severity
| No codes listed |
Provider Responsibilities and Operational Requirements
Submit prior authorization and support concurrent/retrospective reviews
Prior authorization, concurrent review and retrospective review are required components of WHA's UM activities; providers must submit authorization requests per WHA/delegate processes so reviews can determine appropriate utilization and medical necessity.
- Prior authorization, concurrent and retrospective review are part of UM activities and apply to inpatient, outpatient and ambulatory services.
- Authorization reviews must screen clinical and other pertinent information against covered benefits and medical necessity criteria.
Provide documentation for board‑certified medical necessity review
Medical necessity determinations are reviewed case-by-case by board‑certified medical or behavioral health professionals using nationally recognized, evidence‑based review criteria; providers must supply case documentation to support these reviews.
- Decisions use nationally recognized evidence‑based criteria and may include independent specialist review when specific expertise is needed.
- Providers must provide medical records, provider recommendations and other pertinent information for reviewer consideration.
Follow WHA UM criteria for authorization requests
Providers must follow WHA‑approved UM criteria when requesting authorizations; the Utilization Management Committee reviews and approves criteria and oversees referral, authorization and denial data.
- Requests will be assessed using WHA‑approved clinical criteria (e.g., InterQual, MCG, Hayes) where applicable.
- Follow the Plan’s procedures and criteria communicated by WHA and its delegates when submitting authorization requests.
Meet WHA turnaround expectations for authorization decisions
Authorization requests are subject to WHA timeliness goals and CA regulatory timeframes; providers must respond promptly to information requests and expect decision/notification within the stated windows.
- Non‑urgent precertification: goal to decide within 2 business days of obtaining all necessary information; notify practitioner within 24 hours and send written notification to member/MD within 2 business days.
- Urgent precertification: goal to decide and notify within 24 hours (CA regs allow up to 72 hours). Routine prescription meds: decision within 72 hours; exigent meds: within 24 hours; retrospective reviews: within 30 business days.
Comply with delegate review responsibilities and escalation
Prior authorization and concurrent review are generally performed by delegated entities; when delegates perform reviews they must adhere to WHA policies, screening criteria and escalation rules.
- Delegates must screen clinical information against covered benefits and established medical necessity criteria and escalate cases not meeting criteria to a Medical Director or qualified reviewer.
- Whether Plan‑level or delegate reviewers make the decision, they must follow written policies for turnaround times and written notifications.
Coordinate with WHA CRN and case managers for Continuity of Care authorizations
When members qualify for Continuity of Care, WHA’s Clinical Resources Nurse (CRN) assists to obtain specialty referrals and authorizations and to transition care without disruption; providers should coordinate with CRN and delegated case managers.
- CRN works with case managers at contracted medical groups/IPAs to obtain referrals/authorizations as needed.
- Delegates must follow WHA CoC directives until the member is stable for transfer to an in‑network provider of like specialty.
Work with case managers to obtain referrals and authorizations
Case managers facilitate access to providers and services and will work with clinicians to obtain referrals and authorizations necessary to implement care plans; providers should engage the CM to support authorization and care coordination.
- CMs assist with referrals, authorizations and appointments and document member acceptance/declination of services and care plan goals.
- CMs share relevant information with PCPs and other vendors per HIPAA to ensure integrated care.
Follow PBM and WHA processes for pharmacy authorizations
Express Scripts administers pharmacy benefits and delegated UM functions except WHA retains responsibility for specialty drug authorizations and pharmacy‑related appeals; providers must follow PBM and WHA specialty pharmacy authorization processes.
- Express Scripts handles initial coverage determinations and claims adjudication; WHA processes specialty and other pharmacy prior authorization requests and pharmacy‑related appeals.
- Providers should submit pharmacy prior authorization requests per Express Scripts procedures and WHA guidance for specialty drugs.
Provide clinical support for specialty pharmacy authorization reviews
WHA’s Pharmacy Director and Clinical Pharmacist manage pharmacy UM and specialty pharmacy authorizations and participate in P&T oversight; providers may be contacted for clinical information in pharmacy authorization reviews.
- Clinical Pharmacist manages specialty pharmacy authorizations and participates in individual pharmacy case reviews and appeals as needed.
- Providers should be prepared to provide clinical rationale and records to support specialty drug authorization requests.
Submit pharmacy prior authorizations per PBM and WHA procedures
Express Scripts administers standard pharmacy prior authorization processes; WHA retains responsibility for specialty and certain pharmacy prior authorizations and for formulary/P&T governance—submit PA requests per PBM/Plan rules.
- P&T Committee governs formulary exceptions and prior authorization requirements; written policies describe prior authorization for restricted or controlled drugs.
- Providers must follow Express Scripts prior authorization procedures for routine pharmacy PAs and WHA processes for specialty drug PAs.
Support transition care and coordinate authorizations for out‑of‑network treatment
During transitions, members may continue receiving medically necessary care from non‑network providers until stable for transfer; providers should coordinate with WHA/CM to support authorization and transfer planning.
- CoC services apply when members are mid‑treatment at enrollment or when a network provider is terminated mid‑treatment.
- CRN and CMs assist in obtaining authorizations and arranging specialty referrals to minimize disruption.
Provide authorization documentation and relevant clinical records
WHA’s UM Program requires documentation of processes and decisions; providers must supply clinical records and other relevant information to support medical necessity determinations and ensure timely processing.
- UM Program Description and annual evaluations are maintained and used to support determinations.
- Medical necessity reviews must be supported by relevant clinical data and may include consultation with treating practitioners; information is confidential under HIPAA.
Ensure clinical documentation addresses benefit, eligibility and provider recommendations
Medical necessity reviews consider medical records, provider recommendations, covered benefits and eligibility; providers must ensure submitted documentation addresses these elements for each authorization request.
- Decisions are made on a case‑by‑case basis considering condition, needs, covered benefits, eligibility, medical records and provider recommendations.
- When reviewers need further information they may consult treating practitioners; provide timely responses to information requests.
Retain denial notifications and reference cited criteria and appeal instructions
Review decisions must be supported by clinical data and written notifications of denials/modifications must explain reasons, cite criteria used, identify the reviewer and provide appeal instructions; providers should retain records of these communications.
- Notification letters explain the reason for adverse decisions, cite the specific criteria used, and identify the physician reviewer or body issuing the decision.
- Letters include instructions on how to request an expedited appeal or file a grievance with WHA or the DMHC.
Ensure second‑opinion specialists deliver written reports
Specialists providing non‑network second opinions must provide the member and referring physician with a report of findings and recommendations; providers arranging second opinions must ensure these reports are delivered.
- Second opinions are arranged with appropriately qualified like‑specialty providers in‑network if available, or out‑of‑network if necessary.
- Specialist must provide report of findings and recommendations to the member and referring physician.
Coordinate and document interactions with Case Management (CCM)
Case managers document member acceptance or declination of CCM services, care plan goals, and coordinate/share relevant information with other vendors and the member’s PCP following HIPAA; providers working with CCM should expect documented coordination.
- CM documents acceptance/declination, develops patient‑centered care plans with realistic goals, documents progress and barriers, and schedules follow‑up.
- CM shares relevant information with other vendors and the PCP to ensure integrated care.
Be aware authorizations are monitored for appropriateness and timeliness
Prior‑authorization decisions are monitored by WHA for appropriateness, medical necessity and timeliness; inconsistent or inappropriate delegate authorizations may trigger corrective action—providers should ensure submissions meet criteria and timelines to avoid denials.
- WHA monitors authorization/denial logs and delegates’ semi‑annual reports; plan‑wide and group‑specific utilization reports are reviewed annually.
- Inconsistent authorizations may be escalated and can result in corrective action plans for delegates.
Verify member coverage to avoid coverage‑based denials
Authorization outcomes that are not medical necessity decisions depend on the member's purchased health plan coverage; providers should verify member EOC benefits because lack of coverage may result in denial.
- Authorization decisions related to non‑medical‑necessity coverage are governed by the member’s Evidence of Coverage and Disclosure documents.
- Providers should confirm plan‑specific benefits and copayment summaries before proceeding with services.
Follow WHA appeal procedures and expect UM Committee oversight
The UM Committee oversees appeal processes and analyzes delegate appeal activity; providers involved in appeals should follow WHA procedures and recognize appeals may be reviewed by WHA medical leadership or external consultants.
- Member appeals are processed by WHA (behavioral health appeals delegated to Magellan); appeals may be reviewed by WHA's CMO, Medical Director, AMD or external board‑certified consultants.
- Failure to follow approved UM criteria and policies can affect appeal outcomes under UM oversight.
Anticipate escalation to Medical Director when criteria are unmet
Requests that do not meet objective clinical criteria may be referred for escalation; when criteria are not met first‑line reviewers must refer the case to a Medical Director or qualified practitioner for final decision.
- Nurses cannot deny or modify medical necessity requests; cases failing criteria are escalated to a Medical Director or appropriate clinical reviewer.
- Adverse medical necessity determinations are made by a qualified physician or pharmacist reviewer using adequate records and clinical criteria.
Ensure delegated UM performance meets WHA standards to avoid corrective action
Failure by delegates to meet WHA standards or delegated UM processes may result in corrective actions or revocation of delegation; providers working under delegated groups should ensure delegate performance aligns with WHA requirements.
- WHA reviews delegation oversight findings and may request corrective action plans as needed.
- Delegates must provide semi‑annual reports and remain compliant with WHA policies or face corrective action.
No step‑therapy requirements specified—follow PBM/Plan formulary rules
No step‑therapy requirements are specified in these policy chunks; providers should follow PBM or WHA formulary and prior authorization rules where applicable.
- Pharmacy step‑therapy specifics are not described in the cited sections; follow Express Scripts and WHA P&T/PA procedures for coverage and exceptions.
- P&T Committee governs formulary exceptions and prior authorization requirements.
Key Terms and Definitions
Program Background and Scope
WHA's Utilization Management (UM) Program is designed to ensure members have access to medically necessary, appropriate and timely care across care settings. The program applies to all network providers and includes delegation of many UM functions to contracted medical groups/IPAs while maintaining plan-level oversight and retained responsibilities. UM activities include prior authorization, concurrent and retrospective review, medical necessity determinations performed by board-certified clinicians using nationally recognized, evidence-based criteria, and monitoring of authorization appropriateness and timeliness to align decisions with regulatory and accreditation standards.
Policy Revision History
Utilization Management Program Description effective and last reviewed; documents WHA UM program structure, CCM services, delegation, and operational requirements.
UM Program Description published (document year indicated as 2018).
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