Policies and Guidelines > Utilization Management and Prior Authorization
Utilization Management and Prior Authorization
A utilization management (UM) policy is a document containing clinical criteria used by Medica staff members for prior authorization, appropriateness of care determination and coverage. The criteria are specific to the clinical characteristics of the population that will benefit from the treatment or technology. The needs of individual patients who may not meet these criteria must be considered and are addressed by the process in the section labeled "Coverage Issues" on the UM policy.
These policies provide general information concerning our administrative processes. The service may or may not be covered by all Medica plans. Please refer to the member’s plan document for specific coverage information. If there is a difference between this general information and the member’s plan document, the member’s plan document will be used to determine coverage. With respect to Medicare and Medicaid members, these policies will apply unless these programs require different coverage.
Medica may use tools developed by third parties, such as MCG Care Guidelines®, to assist in administering health benefits.
Medica UM policies and MCG Care Guidelines are not intended to be used without the independent clinical judgment of a qualified health care provider taking into account the individual circumstances of each member’s case. Medica UM policies and MCG Care Guidelines do not constitute the practice of medicine or medical advice. The treating health care providers are solely responsible for diagnosis, treatment, and medical advice.
Medica medical policies are a clinical reference that includes UM policies, coverage policies, drug management policies, clinical guidelines and MCG Care Guidelines (if applicable). The coverage policy, UM policy sections as well as the member's plan document should be checked to determine coverage for a particular service.
In the event that a prior authorization is denied and there is new and/or additional objective medical documentation related to the denied service, a new prior authorization request may be submitted for consideration. The prior authorization request must contain new and/or additional objective medical documentation related specifically to the denied service for it to be considered.
For medical services that require prior authorization, as specified in the Prior Authorization List, see additional details below.
Medica requires that providers obtain prior authorization before rendering services.
If any items on the Medica Prior Authorization List are submitted for payment without obtaining a prior authorization, the related claim or claims will be denied as provider liability. The provider will have 60 days from the date of the claim denial to appeal and supply supporting documentation required to determine medical necessity.
Medica reserves the right to conduct a medical necessity review at the time the claim is received.
Policies and Prior Authorization
Important Note: Before using these policies, please read the UM Policy Usage Notice.
Use the links below to navigate to policies and prior authorizations.
Utilization Management Policies
Behavioral Health
Devices/Equipment
Diagnostics
Drugs
Home Care
Inpatient
Medical Services
Surgical Procedures
Transplants – Organ & Bone Marrow
Prior Authorization
The purpose of prior authorization is to evaluate the appropriateness of a medical service based on criteria, medical necessity, and benefit coverage. Please review the current Prior Authorization List of medical services that require prior authorization. For certain services, providers are required to submit a prior authorization form that outlines information important in helping Medica determine the appropriateness of care for Medica members seeking related services.
Medica Prior Authorization List (PDF) (Excludes Medicare Products)
2024 Medicare Prior Authorization List (PDF)
Devices, Diagnostics and Procedures Request Forms
The Prior Authorization Lists above outline all medical services requiring prior authorization from Medica. Requests for the following services can be submitted electronically via the secure provider portal or by using the below forms. *Exception: All Arizona providers must use the Arizona approved forms for all prior authorization requests.
Requests for the following services should be submitted using the forms below:
*Arizona Providers
All Arizona providers must use the Arizona approved forms to submit prior authorization requests. Effective January 1, 2023, prior authorization requests that are submitted on forms other than the below are invalid and will not be accepted or processed pursuant to Arizona Revised Statutes § 20-3406(A).
For pharmacy prior authorizations, see Drug Management Policies.
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