Utilization management describes proactive procedures such as; discharge planning, concurrent planning, precertification and clinical case appeals. It also covers proactive processes such as; concurrent clinical reviews and peer reviews, as well as appeals introduced by the provider, payer or patient.
The PCHP Utilization Management Program applies to all members for whom PCHP contracts to provide medical management services, including all members of Piedmont Community Health Plan and HealthCare. Depending on the contract with an employer or third party, PCHP may be required to provide some or all of its utilization management services. The PCHP Utilization Management Program applies to services provided by in-network and out-of network practitioners and providers.
PCHP utilization management includes the following functions:
- Out-patient care utilization management, including management of primary care and specialist practitioner services, out-patient diagnostic and surgical services, emergency services, durable medical equipment and specialty medication prescription management.
- Out-patient MH/SA utilization management, including management of services by MH/SA practitioners and MH/SA diagnostic testing.
- Pre-admission review and certification for non-urgent medical and MH/SA admissions.
- Admission review, concurrent hospital review/certification and discharge planning for medical and MH/SA hospital services.
- Retrospective review of medical and MH/SA in-patient, emergency and out-patient services.
Piedmont Community Health Plan uses InterQual as the basis for determining medical necessity of medical and mental health/substance abuse care. PCHP recognizes that the InterQual serve as guidelines for care under routine circumstances and that in some instances, depending on the status of the patient or the availability of medical or MHSA services, these guidelines are not applicable.
In order for members to obtain the highest level of benefit coverage, PCHP requires that PCHP patients use medical and MH/SA services by PCHP network practitioners and providers when the appropriate services are available and accessible. Referrals and requests for services outside the local PCHP network are reviewed by and authorized as appropriate by the Medical Director, Director of Medical Management or Psychiatric Medical Director.
The Piedmont Community Health Plan complaint and appeal system is to ensure that a fair an orderly process is available to covered persons and to providers representing covered persons in order to resolve disputes that are related to or arise out of contractual coverage with Piedmont Community Health Plan and Piedmont Community HealthCare.
For more detailed information, please go to the link provided for the Piedmont Community Health Plan Utilization Management Policies and Procedures.
FORMS: Piedmont sometimes uses forms to assist with medical necessity decisions.
4 2018 Codes and Guidance for Preauthorization Requirements - HMO-POS
4 2018 Genetic Testing Requiring Authorization
4 2018 Imaging Codes Requiring Authorization
4 2018 Surgical Codes Requiring Authorization
4 2019 Pre-Authorization Codes - All Plans
NOTE: The 2019 pre-authorization codes is not a complete list and is a work in progress. Providers should contact Medical Management if questioning pre-authorization necessity based on criteria.