Identify whether any entered All services that are reviewed for service requires a medical necessity medical necessity require a N.A. review (separate from a pre-auth). This includes Unlisted Procedures. Identify any professional Site of service restrictions are restrictions related to delivering the not clearly stated on the pre-auth service, e.g. type of provider, site of list. care, etc. For some services, e.g. J1566, a site of care authorization is required but this is not indicated on the pre-auth list. For some services, e.g. the service itself doesn’t need a but a site of care authorization is required. See website #7b comment Identify whether Medication needs NA SCH buys and bills all of their to be obtained from a Specialty medications for UHC-CP Pharmacy. If so, get the contact patients information of the specialty pharmacy Identify if/what supporting Supporting documentation documentation that needs to be sent requirements are not identified with a review request, including on the site. documentation for Unlisted Procedures Identify clinical criteria Met Medical Policies are difficult to find unless you are an experienced user. (They are under Tools and Resources rather than Clinician Resources)
Identify whether any entered service requires a medical necessity review (separate from a pre-auth). This includes Unlisted Procedures. N.A. All services that are reviewed for medical necessity require a Identify any professional restrictions related to delivering the service, e.g. type of provider, site of care, etc. Site of service restrictions are not clearly stated on the pre-auth list. For some services, e.g. J1566, a site of care authorization is required but this is not indicated on the pre-auth list. For some services, e.g. the service itself doesn’t need a but a site of care authorization is required. See website #7b comment Identify whether Medication needs to be obtained from a Specialty Pharmacy. If so, get the contact information of the specialty pharmacy NA SCH buys and bills all of their medications for UHC-CP patients Identify if/what supporting documentation that needs to be sent with a review request, including documentation for Unlisted Procedures Supporting documentation requirements are not identified on the site. Identify clinical criteria Met Medical Policies are difficult to find unless you are an experienced user. (They are under Tools and Resources rather than Clinician Resources)
UHC-CP%20Detail%202.docx