Certain covered services require prior authorization (pre-approval) from your PCP's affiliated medical group or from WHA in some cases, to make sure they are paid under your health plan benefits.
Your PCP should know when pre-approval is needed. PCP staff will notify your medical group or WHA when you need to see a specialist or get another service that requires pre-approval. Decisions are made by qualified medical professionals (doctors, pharmacists and nurses), but only experienced physicians and pharmacists can deny or modify a requested service.
You do not need pre-approval for initial emergency room treatment. You may also see a network eye specialist once a year for a routine eye exam, if covered, and women may access obstetrical or gynecological services without pre-approval. You just need to make sure the specialist is in WHA's provider network. See Provider Directory on this website for participating network specialists or call Member Services.
A decision to pre-approve, modify or deny a specialty or service referral request must be made within certain timeframes. These are based on the urgency of your medical condition and treatment needs, but most decisions are made within five business days of receiving necessary information to make the decision. If fast handling of your case is needed due to urgent medical needs, your doctor may ask for an "expedited" review. These will be completed by the plan as soon as possible based on your situation, but no later than 72 hours of receipt of the request and pertinent information to make a decision.
Your doctor(s) and medical group will receive a phone call, fax or electronic notice of the decision within 24 hours of the decision. This is followed by written notice mailed to you, your PCP and the specialist within two days. If denied, the notice includes an explanation of the reasons for the denial or modification and information on how to file an appeal with WHA Member Services. It also includes information on how to contact the California Department of Managed Health Care for an independent review of your case (call toll free at 888.HMO.2219 or TDD services at 877.688.9891).
Insurance eligibility and benefits are verified first to make sure you have effective coverage. Your referral request is also checked to see if the specialty service you need will be provided by a WHA network provider. Experienced reviewers (nurses, pharmacists or doctors) then evaluate your individual situation and compare your relevant medical records against review criteria that are based on recognized standards of practice for your diagnosis. Using established medical criteria helps reviewers decide if requested services are appropriate and medically necessary, and they promote fair and consistent decisions. During these reviews, Plan benefits and individual circumstances of the patient are also considered. Financial incentives or compensation are not linked to these decisions or to the withholding of care.
Review criteria are based on sound clinical principles and treatment practices, and involve actively practicing board certified specialists in their development. All criteria/guidelines used by WHA and its medical groups must be approved annually by WHA's Quality Committee and Board of Directors to make sure they are still appropriate and current.
Criteria primarily used by WHA’s physician reviewers to make medical necessity decisions at the health plan level include the following sources:
- MCG® (formerly Milliman Care Guidelines) – Acute, Ambulatory & Chronic Care guidelines
- UpToDate® – Evidence-based physician authored clinical decision support resource
- Hayes New Technology Assessment guidelines – Experimental guidelines
- Optum Complete Guide to Medicare Coverage Issues
Most criteria and guidelines are protected by copyright, however if a service is denied for medical necessity reasons, you will receive written rationale with excerpts or references to the criteria that was used to make the decision. You will also be provided with information on how to submit an appeal or a request for re-review of your case by another physician if you do not agree. To obtain more information about the utilization management or appeal processes, decision criteria or pharmaceutical management procedures, please call WHA Member Services at 916.563.2250 and ask for the Medical Management department.
WHA's clinical staff is available by calling Member Services and asking to speak with a Medical Management representative. If you prefer to leave a message for WHA's clinical staff about a UM inquiry or you call after hours, select option 7. The message service is available 24 hours a day/7 days a week. All messages left after hours will be answered with a return call on the next business day. Inquiries can also be faxed directly to WHA's Medical Management department at 916.568.0278.
New diagnostic and surgical procedures, medicines and other healthcare interventions that are not yet considered the usual standard of care and practice (according to national and local medical communities) are reviewed by WHA to see if they are safe and effective before they become covered benefits. If your doctor requests pre-approval for a service that could be considered experimental, it will be forwarded to WHA for investigation and decision-making. WHA reviewers use special new technology assessment criteria developed by Hayes, Inc. to help with these decisions. If no criteria exist for the requested service or it is too new to adequately evaluate through other resources, WHA may forward the case to outside, independent physician reviewers who provide expert opinions and recommendations. Service requests that are determined to be experimental after thorough investigation are not covered benefits.
Sometimes WHA’s investigation will reveal that the new technology is no longer considered experimental and may be included as a regular member benefit. If WHA’s medical professionals decide a new technology is unproven and your doctor’s request is denied, you and/or your doctor have the right to appeal the decision.
For additional information regarding WHA’s Utilization Management decisions and processes, call Member Services and ask to speak with a Clinical Resources nurse.