Second Level Make certification or denial determinations. The determination is: Reviewers Based on hospital documentation that supports medical necessity and (Physicians) appropriateness of setting. Sensitive to the local healthcare delivery system infrastructure. Based on the physician clinical experience, judgment and reviewer’s generally accepted standards of healthcare. Only physicians may render an adverse determination for medical necessity. Note: See the Reconsideration Process section of this manual Pended Review for Additional Information If the review cannot Timeframe for Review Type proceed because ... Then submission Prior Authorization of Clinical information is The hospital Liaison is The hospital will supply Elective Procedure needed by the first faxed a Request for additional information level nurse reviewer to Additional Information within 1 business day satisfy criteria. and status shown as from the date on notice pended on or the request will be eQSuite™. canceled. Submitting Additional Information Prior Authorization requests may require additional information to help meet medical necessity: The hospital should check all Prior Authorization requests online within 24 hours of submission. The status will display as, at nurse, at physician or pend. For pended reviews, a notice of for Additional will be faxed to the hospital Liaison and is available for view “Request Information” online. You may submit the additional information needed through under the Request eQSuite™ for tab. Please download the User Guide from our Web site. All prior Addt’l Info eQSuite™ authorization information is available under the PriorAuthResources tab. Reconsideration Review Process If the hospital or physician disagrees with the adverse determination made by eQHealth, a request for reconsideration may be submitted. The hospital or treating physician/clinician may request an expedited reconsideration request using the eQHealth Prior Authorization Reconsideration Request form (included in Section IV of this manual). This request for reconsideration must be submitted within 10 business days from the date of the denial notice. A second eQHealth physician reviewer, who is board certified, and not involved in the initial decision, will review the reconsideration request and make a determination. The following apply to reconsideration requests: If the reconsideration request in untimely with no good cause, a notice is sent that the request is invalid. Upon reconsideration review, if the denial is upheld a notice is sent and there is no other course of action from eQHealth.
Second Level Reviewers (Physicians) Make certification or denial determinations. The determination is: Based on hospital documentation that supports medical necessity and appropriateness of setting. Sensitive to the local healthcare delivery system infrastructure. Based on the physician reviewer’s clinical experience, judgment and generally accepted standards of healthcare. Only physicians may render an adverse determination for medical necessity. Note: See the Reconsideration Process section of this manual Pended Review for Additional Information Review Type If the review cannot proceed because ... Then Timeframe for submission Prior Authorization of Elective Procedure Clinical information is needed by the first level nurse reviewer to satisfy criteria. The hospital Liaison is faxed a Request for Additional Information and status shown as pended on eQSuite™. The hospital will supply additional information within 1 business day from the date on notice or the request will be canceled. Submitting Additional Information Prior Authorization requests may require additional information to help meet medical necessity: The hospital should check all Prior Authorization requests online within 24 hours of submission. The status will display as, at nurse, at physician or pend. For pended reviews, a notice of “Request for Additional Information” will be faxed to the hospital Liaison and is available for view online. You may submit the additional information needed through eQSuite™ under the Request for Addt’l Info tab. Please download the eQSuite™ User Guide from our Web site. All prior authorization information is available under the PriorAuthResources tab. Reconsideration Review Process If the hospital or physician disagrees with the adverse determination made by eQHealth, a request for reconsideration may be submitted. The hospital or treating physician/clinician may request an expedited reconsideration request using the eQHealth Prior Authorization Reconsideration Request form (included in Section IV of this manual). This request for reconsideration must be submitted within 10 business days from the date of the denial notice. A second eQHealth physician reviewer, who is board certified, and not involved in the initial decision, will review the reconsideration request and make a determination. The following apply to reconsideration requests: If the reconsideration request in untimely with no good cause, a notice is sent that the request is invalid. Upon reconsideration review, if the denial is upheld a notice is sent and there is no other course of action from eQHealth.
Prior%20Auth%20Provider%20Manual%20Rev%201.docx