Prior Authorization Reviews & Decisions
Certain covered services require prior authorization (pre-approval) from the PCP's affiliated medical group/IPA or from WHA in some cases, to ensure benefit coverage and/or medical necessity. Each medical group has its own list of services that require prior authorization. Contact the Medical Management/UM Department of your patient's assigned group for specifics.
Service requests requiring prior authorization are typically reviewed by doctors and nurses at the group level, but some reviews are ultimately performed at the plan level, depending on the type of request. Only experienced physicians can deny or modify a request at either level. Authorization requests (referrals) should be sent to the Medical Management/UM Department of your affiliated medical group or IPA, and not sent directly to WHA. If WHA needs to make the authorization decision at the plan level, your group will forward the request to WHA for review.
Prior authorization is not needed for initial emergency room treatment. Members can self-refer within the network for their annual eye exam (when covered) and OB/GYN visits. In addition, Advantage Referrals to out-of-group network specialists do not require prior authorization, but a referral to your group is needed for claims payment purposes. Your affiliated medical group or IPA should know which services require prior authorization and those that can be directly accessed by a member.
By law, a decision to pre-approve, modify or deny a specialty or service referral request must be made within certain time frames. Turnaround times are based on the urgency of your patient's medical condition and treatment needs, but most decisions are made within five (5) working days of receiving necessary information to make the decision. If fast handling is needed due to urgent medical needs of your patient, you may request "expedited" handling. Expedited requests submitted by the member's physician will be completed as soon as possible based on the patient's individual situation and urgency, but no later than 72 hours of receipt of the request and sufficient information to make the decision.
The PCP/group, member and specialty provider, if any, are notified in writing of the authorization decision. The requesting physician/provider will initially be notified of the decision by phone, fax and/or electronic message within 24 hours of the decision. In addition, a written notice of the decision is mailed to the PCP/group, member, and specialist when applicable, within two (2) working days after the initial notice was made for denials, and within three (3) working days of an approval. Adverse decision notices include an explanation of the reasons for the denial, delay or modification and provide information on how/where to file an appeal with WHA. The notice also includes information on how to contact the California Department of Managed Health Care (DMHC) for an independent review of the case.
Insurance eligibility and benefits are verified first to make sure the member has effective coverage. The referral/request is also checked to see if the requested service is from a WHA network provider. Experienced nurse/physician reviewers then evaluate the member's individual situation and compare relevant medical records against review criteria based on recognized standards of practice for the member's diagnosis. In addition to relying on their own clinical expertise, use of established medical criteria helps reviewers decide if requested services are appropriate and medically necessary, and promotes fair and consistent decisions.
WHA's physician reviewers make coverage decisions related to appropriateness of care and services using available medical information about the patient and criteria that are based on recognized standards of medical practice. 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.
At the plan level, WHA primarily uses MCG® (Milliman Care Guidelines) and Hayes New Technology Assessment & Experimental Treatment Guidelines to help physician reviewers make medical necessity decisions. Some contracted medical groups/IPAs also use InterQual® criteria or their own internally developed guidelines that must meet stringent requirements and receive committee approvals.
Medical necessity 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. Decisions related to covered benefits are based on contracts and language contained in the members' individual "Evidence of Coverage (EOC) and Disclosure" booklets, specific to their group health insurance plan. The EOC specifies covered benefits and benefit limitations and exclusions. Whenever changes are made to the EOC documents, they must be reviewed and pre-approved by the Department of Management Health Care (DMHC), which is responsible for licensing HMOs in the state of California.
Yes, WHA's clinical staff is available during regular business hours Monday through Friday, 8 a.m. to 5 p.m. by calling Member Services at 916.563.2250, 888.563.2250 or 888.877.5378 TTY/TDD and asking to speak with a Medical Management representative. If the caller prefers to leave a message for WHA's clinical staff about a UM inquiry or calls after hours, select option 4. 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.
During regular business hours (Monday through Friday, 8 a.m. to 5 p.m.) a network physician may speak directly with WHA's Chief Medical Officer/Medical Director by calling the phone number listed in WHA's Provider Manual and included in all Denial letters. If a confidential voice message is left, a return call will be made by the next business day.
A Standing Referral allows a member access to a specialist and/or specialty care services from a provider with expertise in treating a medical condition or disease that requires ongoing monitoring. A standing referral will be issued if a PCP determines in consultation with a specialist or specialty care center and the medical group’s Medical Director that the member needs continuing specialist care. After the standing referral is made, the specialist will be authorized within his/her area of expertise and training to provide health care services to the member, subject to the terms of the treatment plan. The contracted medical group may limit the number of specialist visits or the period of time that the visits are authorized and may require the specialist to provide the PCP with regular reports on the services provided to the member. The treatment plan should be agreed upon by the PCP, specialist and medical group’s Medical Director, or designee, with the member’s approval.
Emergency Hospital Admissions
WHA's contracted medical groups/IPAs are responsible for conducting concurrent review of patients admitted to acute hospitals from the ER when the hospital is located within the group's defined service area, which varies among groups. WHA, at the plan level, is responsible for conducting concurrent review of patients admitted through the ER to acute hospitals located outside the health plan's service area. When a patient is hospitalized outside the service area, requires ongoing care, and is stable for transfer, WHA's concurrent review nurse collaborates with the hospital's discharge planner and group's UM nurse to facilitate the transfer to a network facility.
Yes, per California law, all members must be allowed a second opinion when requested, but certain restrictions apply. The second opinion consultation must be provided by a physician with the same specialty as the first opinion physician, and the second opinion provider must be in WHA's network. Prior authorization is needed to ensure coverage. In-network review decisions are made at the medical group level. If the specialty needed for a second opinion is not available within WHA's provider network or network services cannot be provided in a timely manner consistent with the member's situation, the request is forwarded to the health plan level for decision-making, which may result in approval of a non-network second opinion.
Prior authorization timeframes for making decisions for second opinion requests are the same as for all other routine or expedited service requests (completed within five working days for routine reviews, or within 72 hrs. of receiving sufficient information for expedited handling). For adverse decisions, notification is provided to the requesting physician initially by phone call, fax or EMR within 24 hours of the decision. Written notice of all decisions is made to the physician/group, member and specialist if applicable, within three (3) working days of the decision for routine reviews, and sooner if expedited handling is required. If the plan makes the decision to approve or deny a non-network second opinion, WHA is responsible for notifying all affected parties within the required timeframes.
New diagnostic and surgical procedures, drugs and other healthcare interventions that are not FDA approved or not yet considered the usual standard of practice according to the national and local medical communities, are reviewed by WHA to see if they are safe and effective before they are included as covered benefits. Services determined to be "experimental" by WHA are not covered benefits. If you want your patient to receive a service that might be experimental, submit your request to your affiliated medical group. It will be screened and forwarded to WHA for investigation and decision-making if experimental status is a possibility.
WHA's physician reviewers use special new technology assessment criteria developed by Hayes, Inc. to help with potentially "experimental" 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 its outside contracted vendor, iMedecs, where independent board-certified physician reviewers provide expert opinions and recommendations. For service requests determined to be experimental, WHA will issue the appropriate denial notices to all affected parties following required timeframes. If a requested service is no longer considered experimental by WHA, it will be returned to your affiliated medical group for medical necessity review and authorization determination.
WHA, at the plan level, reviews all requests for organ, stem cell and bone marrow transplants, but only after the initial transplant evaluation is completed at the group level. If you have a patient who needs a transplant evaluation, send the referral to your affiliated medical group for prior authorization. If the evaluation results in a recommendation for a transplant, send the referral to the Medical Management/UM Department of your affiliated medical group and it will be forwarded to WHA for decision-making. WHA will review the records and send the decision notification letters to the physician/group and member within established authorization time frames.
Once WHA validates the medical necessity of the transplant request, and issues the initial approval notices to requesting parties, all transplant related services, including hospitalization for the surgery/procedure, are reviewed and authorized by the member's assigned medical group.
Send the request (referral), any relevant patient medical records, and specific information about the clinical trial to the Medical Management/UM Department of your affiliated medical group, and they will forward it to WHA for decision-making. The process is similar to the one used for plan level transplant reviews. Authorization decision notices are issued by WHA to all affected parties.
Continuity of Care
California law allows certain new health plan members to continue to receive some limited services from providers they accessed under their previous health plan, even if those providers are not in WHA's network. These non-network services are provided under WHA's Continuity of Care program. Typically, those who qualify are receiving active or ongoing care/treatment that should not be interrupted when they become effective with WHA. Allowing new members' access to their current non-network specialists provides more time to establish a relationship with their new WHA PCP, and to transition their care to other network providers when it's more appropriate for their individual situation.
To qualify for limited non-network CoC services, the new member must meet specific criteria and submit an application to WHA for review and prior authorization. Examples of qualifying events include, but are not limited to: new members who are pregnant when they become effective with WHA, have scheduled surgeries already approved by their previous health insurance plan, or are undergoing active radiation treatments or chemotherapy for cancer.
WHA is responsible, at the plan level, for reviewing and making CoC authorization decisions for new health plan members. When a decision is made, WHA notifies the member and non-network provider in writing. WHA also notifies the member's new WHA PCP and/or medical group so a case manager can work directly with the patient and treating physicians to transition care/services into WHA's network at the appropriate time. New members with CoC approvals to receive services from certain non-network specialists are still required to establish care with their new WHA PCP and access other care/services from network providers as appropriate.
Case management services are available to any WHA member meeting program criteria. These services are provided by experienced nurses employed by the member's assigned medical group or IPA. Typically, CM services are provided to members with complex or multiple medical conditions that require many visits to specialists or when other multiple services are needed. If your patient needs help managing his or her healthcare needs, please make a referral or call the Medical Management/UM dept. of your affiliated medical group asking for case management assistance. Case managers serve as patient advocates and personally help members through the complexities of the healthcare system.
Anyone can ask for CM assistance, including the member, the member's physician, or a family member/caregiver/friend, etc. Send an online or faxed referral request or to contact your affiliated medical group's Medical Management/UM Department by phone:
Hill Physicians Medical Group: 800.445.5747
Mercy Medical Group: 916.379.2885
Meritage Medical Network: 415.884.1840 or 800.874.0840
NorthBay Medical Group: 707.646.4241
UC Davis Medical Group: 916.734.9900 or 800.445.3936
Woodland Medical Group: 530.662.3961 x4361
The following conditions are part of WHA's Disease Management Programs:
Asthma: 5-56 years
Coronary Artery Disease (CAD): 18-64+ years
Diabetes: 18-64+ years
Depending on the severity of the patient's illness, health care professionals may contact participants by telephone and/or through educational mailers that are related to his or her condition. Health care professionals coach participants on nutrition, medication management, physical activity and community resources. In addition, as a health care provider, you will receive progress reports that may include patient-specific and evidence-based treatment recommendations that allow you the opportunity to make any appropriate adjustments to the current plan of care.
WHA provides this service as a benefit to our members so there is no additional cost to participate in the program.
Patients can be identified and/or referred by one of these methods:
Physician Referral: As a health care provider, you are most likely to know when one of your patients would benefit from one our disease management programs. You can:
Contact Optum® directly at 877.793.3655
Complete the online WHA Disease Management Program Referral Form and fax it to WHA at 916.568.0278 or mail to: WHA, Attention: HPDM Department, 2349 Gateway Oaks Drive Suite 100, Sacramento, CA 95833.
Members can also self-refer by completing the WHA Disease Management Program Referral Form
Optum complies with all applicable provisions of law relating to the privacy, confidentiality, security, integrity, transmission or exchange of medical, personal, consumer or financial information obtained and maintained by Optum.
Optum is a business associate of WHA and is a covered entity under the HIPAA Privacy and Security Rules. Optum does not use or disclose Protected Health Information (PHI) for any purpose other than as required to perform its agreements with health plans or as otherwise required or permitted by law. Optum uses appropriate safeguards consistent with reasonable practices in the industry to ensure that PHI is not otherwise used or disclosed.
The programs are voluntary and participants can choose to leave or opt out of the program at any time by simply contacting Optum or WHA.
As a healthcare provider, you will receive progress reports that may include patient-specific and evidence-based treatment recommendations that allow you the opportunity to make any appropriate adjustments to the current plan of care. You may be contacted by fax or phone depending on the severity of your patient's needs at the time of the participant-call. The types of faxes you may see and the reason for the information are as follows:
Optum Report: Based on specified clinical criteria and/or in the nurse's judgment, the clinical information reported requires a practitioner's review within 24 hours.
Medication Report: A medication issue is identified that needs to be reviewed by the physician.
Pre-visit Report: Sent prior to a scheduled office visit. May alert the physician to non-urgent issues or if the participant screens positive for depression.
Status Report: Issued when there is clinical and/or psychosocial information that should be transmitted to the practitioner, but does not require review within 24 hours.
WHA retains responsibility for responding to and resolving concerns or complaints about Optum's staff or services. General questions or concerns can be directed to Member Service.
You can verify eligibility 24 hours a day by logging onto WHA's password protected pages.
You can reach WHA's Member Services department at 916.563.2250 or toll-free at 888.563.2250 Monday through Friday between 8 a.m. and 6 p.m. WHA is closed on all Federal Holidays.
You can sign up for access online at mywha.org/signup.
Under DMHC's definition for "Missed Appointment Fees," which is defined as, "fees charged by a Provider against a WHA member who fails to keep an appointment with the Provider for a service that would have been covered by WHA, and fails to inform the Provider with advance notice as required and disclosed by the Provider," a Provider may charge a "reasonable" missed appointment fee as long as the Provider has established a written policy for such fees and has disclosed its policy to each member in advance.
These services are available at no cost to members.
MyWHA Wellness is WHA's wellness program that went into effect on January 1, 2016. This improved wellness program is provided by Optum through mywha.org/wellness. Optum is a familiar name to many WHA members, particularly those who have been enrolled in one of our disease management programs or have used our Nurse 24 advice line services..
The goals of MyWHA Wellness are:
- Give you information about your current health.
- Help you set personalized and realistic wellness goals.
- Provide the tools and resources you need to reach your goals.
Start by taking the wellness assessment. It will give you a wellness score, along with a personalized report about your medical and behavioral health risks. You’ll also identify personal goals for improving your health using Optum’s tools.
No, the MyWHA Wellness website and services are in no way intended to be professional medical advice, or substitute for professional medical advice, nor do they provide medical services. Furthermore, the MyWHA Wellness website and services are intended for educational purposes only. Products and services available on the MyWHA Wellness website are not insurance. MyWHA Wellness expressly prohibits you from using information and services on its website to diagnose, treat, cure, or prevent any medical condition. WHA recommends that you consult a physician for treatment of any medical condition or medical advice. Application or reliance on any of the content, techniques, ideas, and suggestions accessed through mywha.org/wellness is at your sole discretion and risk.
If you are an active WHA member, you are eligible. WHA offers the tools provided through MyWHA Wellness as a basic benefit to our members at no additional cost.
No, some personal health improvement programs are not appropriate for individuals who have certain medical or other health conditions. . However, other tools, such as the health library and tracking tools, are appropriate for most individuals.
YES, YOU ARE STRICTLY RESPONSIBLE FOR SEEKING MEDICAL ADVICE FROM A PHYSICIAN PRIOR TO PARTICIPATING IN ANY PERSONAL HEALTH IMPROVEMENT PROGRAM DISCUSSED OR ADDRESSED IN MYWHA WELLNESS. You may not be aware of a medical condition from which you suffer; therefore, you should not participate in the personal health improvement programs discussed in MyWHA Wellness prior to seeking the advice of a physician.
It's easy. Visit mywha.org/wellness. Log in or register in the top right corner. Once you provide the necessary information, you should be able to access the wellness tools right away.
It’s important to take your wellness assessment right away so you can take full advantage of the wellness tools. To do that, after logging in, click on “Get Started” in the wellness assessment box. Then click on “Get Started” again and start answering the questions. You can save and close the program at any time if you don’t have time to complete it all at once. Submit when you are done.
There is no cost to our members for using MyWHA Wellness. WHA offers this program as part of your basic benefit. WHA members with the basic benefit have access to online coaching services.
It’s important to take your wellness assessment right away so you can take full advantage of the wellness tools. It will give you a wellness score, along with a personalized report about your medical and behavioral health risks. You’ll also identify personal goals for improving your health using Optum’s tools.
To take your wellness assessment, after logging in at mywha.org/wellness, click on “Get Started” in the wellness assessment box. Then click on “Get Started” again and start answering the questions. You can save and close the program at any time if you don’t have time to complete it all at once. Submit when you are done.
During the initial registration process, MyWHA Wellness collects information from you such as name, gender, date of birth, phone number, email address, and mailing address. Once registered, you may enter health-related information such as weight, height and health habits using certain website features, such as the health progress assessment (HPA) and health trackers.
Personal health information is not provided to employer groups but is provided via an extract for WHA data purposes. A combined risk and engagement information is provided at all purchase levels where data is available. Individual-level engagement activity information is provided at all levels for employer groups to administer their incentive, if applicable (detail reports, HPA completer reports, etc.).
Wellness tools include video and audio online coaching courses, nutrition and exercise planners; and 11 health trackers such as those for your blood sugar, cholesterol, weight, sleep, stress, peak flow and activity level. A health library is available that includes videos and articles with the latest information on a variety of health topics, such as workout tips, help with quitting smoking, yoga, recipes, newsletters and much more.
MyWHA Wellness will not release, sell, rent or trade your personal information to any third party without your permission unless the law requires it or to protect its own rights and properties. Personal information includes, but is not limited to, name, e-mail address, mailing address, phone number, user I.D. and passwords, credit card information and personal health information. Optum never shares any information with any third parties.
Once your wellness assessment is completed changes cannot be made. The same is true for trackers you complete, as that becomes part of your online record. Please remember, personal health information cannot be removed from the system and will be retained for a minimum of seven years in accordance with Optum’s record retention policy. Your member account, however, may be disabled upon written request, using the contact information listed below.
In order to maintain the confidentiality of personal information, MyWHA Wellness through Optum enforces strict company-wide policies regarding privacy, security, and confidentiality in accordance with HIPAA security requirements. Optum secures personal information in an isolated database with tightly restricted access. Only authenticated employees are allowed to gain such access. Review of web security is on an ongoing basis. In addition to daily security administration and response activities, the organization undergoes an overall security review on an annual basis. Optum uses Secure Sockets Layer (SSL) technology to protect the security of online order information.
Call Optum at 877.793.3655, option 3.
Call Optum at 877.793.3655, option 7.
Call 877.719.9004 (Optum’s Service Desk) with any questions about the site or your program. Service Desk Hours are Eastern Time:
Monday to Friday: 8 a.m. to 11 p.m.
Saturday to Sunday: 9 a.m. to 6 p.m.
Excludes nationally-observed holidays.
You should call WHA Member Services at 888.563.2250. Different employer groups may have different arrangements regarding telephonic coaching.
The WHA Preferred Drug List show which generic (1st tier) and brand name (2nd tier) products are preferred agents. Most oral drugs not listed in the PDL are covered at the 3rd tier copayment but do not require a Prior Authorization (PA).
All Specialty drugs, oral, injectable, inhalation, etc. require Prior Authorization for coverage. A few oral non-specialty drugs require a PA. Some examples are: Celebrex, Restasis and Vfend. There are drugs that have step therapy requirements. For example, an ACE inhibitor must be tried before approval of an ARB drug. Some drugs have quantity limitations that require a PA to over ride. Examples include: sleeping pills limited to 21 doses per 30-day supply, asthma inhalers limited to two units, and triptan drugs for the treatment of migraine. These are only partial lists.
The WHA Preferred Drug List includes both the preferred Brand and generic drugs and is located in the Pharmacy section of the Provider website.
All Specialty drugs require a prior authorization for coverage and are limited to a 30-day supply.
Specialty medications can be obtained through WHA's exclusive specialty pharmacy network. This network includes Accredo (Express Scripts' specialty pharmacy), UC Davis, and Dignity Health on site pharmacies. WHA will allow up to two initial fills at local retail pharmacies to make sure your patient gets started on their medications in a timely manner. All other fills will be limited to WHA’s specialty network. For convenience, some specialty medication refills can be ordered by your patients online, safely and securely, through Express-Scripts.com. Your patients can also reach Accredo at 877.895.9697. Prescribers can call in prescriptions directly to Accredo at 866.759.1557.
Medications for infertility are only covered when the employer has purchased a separate policy called the Infertility Rider. All infertility services require prior authorization from the medical group for the services and from WHA for the medication costs. Members must refer to their Explanation of Coverage for restrictions and exclusions regarding coverage for infertility services.
No, Express Scripts' Mail Service pharmacy is located in the State of Nevada. Nevada pharmacy law does not allow a pharmacist to change a prescription written for a 30-day supply to fill it as a 90-day supply even if there are enough refills.
Only Insulin and diabetic supplies are covered under the WHA's pharmacy plan. No other OTC products are covered.
WHA has a large pharmacy network through Express Scripts. All contracted pharmacies are listed in our Provider Directory at the end of each county listing. Members can also contact WHA Member Services.
Policies & Guidelines
Medical Records Management & Health Information Management
WHA is required by our accreditation and licensing agencies to review medical record keeping systems of its contracted providers.
Contact WHA's Member Services department and ask to speak with WHA's Corporate Quality Leader or the Quality Improvement department with any questions regarding medical record requirements.
Access & Availability
The effective date of the Timely Access Regulations is 1/17/11.
The Timely Access Regulations establish appointment availability standards for primary care physicians, specialist physicians, ancillary providers (physical therapy, radiology, laboratory, etc.), and mental health providers.
No. The Timely Access Regulations do not apply to:
- Preventive care (including routine physicals and well-child care);
- Periodic follow-up care, including but not limited to, standing referrals to specialists for chronic conditions, periodic office visits for pregnancy, cardiac care, and mental health care;
- Laboratory and radiological monitoring for recurrence of disease.
All of these types of care are not subject to the Timely Access Regulations and may be scheduled consistent with professionally recognized standards of practice.
The applicable waiting time for a particular appointment may be extended only if the referring or treating licensed health care provider, acting within the scope of his or her practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the patient.
No. This determination may be made only by the referring or treating licensed health care provider, acting within the scope of his or her practice and consistent with professionally recognized standards of practice.
No. The Timely Access Regulations do not set forth specific chart documentation standards, other than to say that this decision must be documented in the relevant record.
"Advanced access" means offering an appointment to a patient with a primary care physician (or nurse practitioner or physician's assistant) within the same or next business day from the time an appointment is requested (or a later date if the patient prefers not to accept the appointment offered within the same or next business day). If a primary care physician offers "advanced access," it is considered to be in compliance with the appointment availability standards in the Timely Access Regulations.
Health plans are required to measure and monitor the performance of their provider networks against the appointment availability standards. As part of this measurement and monitoring process, health plans will focus on overall performance trends and patterns at the IPA/medical group level.
For patients calling after-hours with urgent, non-emergency, situations that cannot wait until the next business day should receive on of the following options:
- When speaking to a live person:
- Stay on the line and be connected to the doctor on call.
- Leave a name and number and a physician or qualified healthcare professional will call you back within 30 minutes.
- Reach the doctor at another number, which is given.
- Appropriate Emergency Instructions:
- If a patient calling after-hours states he/she is dealing with an emergency the patient must be told to call 911 or referred to the nearest emergency room.
WHA contracts with Optum,® an accredited organization to provide nurse advice line services to all WHA members 24 hours a day, seven days a week, 365 days a year. Optum also has bi-lingual nurses that can assist your patients whose preferred spoken language is Spanish.
WHA's dedicated phone line for the Nurse Advice Line is 877.793.3655.
WHA's Advantage Referral Program (ARP) allows our members more options when specialty care is needed. Under this unique program members may seek care and services from specialists associated with medical groups other than their own. To qualify, the ARP specialist must be in WHA's network and accept Advantage Referrals. Prior authorization is not required, but a referral from the member's PCP is needed to establish medical necessity and identify the type of specialist that is needed.
Yes, but not all WHA contracted specialists accept Advantage Referrals. Physicians that are not in the program are identified in WHA's Provider Directory with a special symbol. The Provider Directory online or you may call a Member Services representative for assistance, Monday to Friday between 8 a.m. and 5 p.m. at: 916.563.2250.
Advantage Referral (AR) specialists may provide consultations and order routine lab work and plain film x-rays when needed. If additional testing, procedures, surgeries or other non-routine services are needed, the AR specialist must notify the member's assigned PCP and obtain prior-authorization to ensure further coverage. The program does not include rehab, PT, ST or OT services from non-group WHA providers.
Send claims for AR services to the Claims Dept. of the member's assigned medical group or IPA, and mark them as "Advantage Referral" for faster processing.
WHA encourages practitioners to give their Medical Group/IPA as much prior notification as possible when leaving a Group. WHA is required by regulatory and accrediting agencies to notify members that are affected by the termination of a practitioner or practice group in general, family and internal medicine or pediatrics, at least 30 calendar days prior to the effective termination date.
Physicians interested in participating in WHA's provider network may contract with WHA through a contracted Medical Group or IPA.
WHA's provider directory is available online. To request a printed copy of WHA's Provider Directory contact WHA's Member Services department at 916.563.2250 or toll-free at 888.563.2250.
WHA's online Provider Directory is updated within seven business days following receipt of new or updated information from a contracted medical group/IPA, practitioner, or a contracted facility.
Any and all provider demographic changes must be communicated to contracted medical group/IPA. It is the Groups responsibility to report such changes to WHA.
Practitioners are required to complete the re-credentialing process every three years or 36 months.
Provider disputes for denied, contested or adjusted claims issued by WHA should be filed with WHA and not with the contracted medical group. For PDR inquiries or filing instructions, you can contact WHA at 916.563.2250 or 888.563.2250. Or you can mail a written request, along with your denial notice, a brief description of your issue and any other relevant information to: Western Health Advantage, Attn: Provider Dispute Resolution 2349 Gateway Oaks Drive, Suite 100 Sacramento, CA 95833.
If a dispute is submitted by a provider on behalf of an enrollee, it will be handled through WHA's appeal/grievance process, rather than the provider dispute process.
Quality & Safety
For further information or questions regarding WHA'S QI Program please call WHA's Member Services at (916) 563-2250 or toll-free at 888.563.2250 and ask to speak with WHA's Corporate Quality Leader or Clinical Quality Manager.
Yes. A report card of WHA's performance on key health care and service measures is available on the State of California's Office of the Patient Advocate (OPA) website.
A list of The Joint Commission accredited hospitals and their survey results are posted in the "Quality Check" section of The Joint Commission website. WHA's provider directory denotes the accreditation status of all WHA contracted hospitals.
- December 7, 2018