Utilization Management – Providers

Welcome healthcare professionals!

FirstCarolinaCare values you as a provider and recognizes that our member’s health is in your hands. We share your goals to ensure that your patients/our members receive quality healthcare to improve their health and well-being.

We want to ensure that all providers are aware of the clinical criteria and guidelines utilized by FirstCarolinaCare (FCC) to make medical necessity decisions. In making these decisions we’re guided by evidence-based care guidelines from InterQual®, and from CMS National and Local Coverage Determinations. We also utilize medical policies and procedures from our organizational partner, Health Alliance Medical Plans. Information regarding our clinical review criteria can be found here.

In addition to the evidenced-based criteria, coverage determinations are based on your patient’s benefit plan and clinical information submitted with the prior authorization request.

FCC partners with eviCore Healthcare, a nationally recognized and accredited company with more than 25 years of experience in utilization management. eviCore offers integrative and innovative care management and specialty expertise, helping us enable better outcomes for our members and providers. eviCore specializes in reviews for the following areas of care:

• Lab management – genetic testing.
• Radiology/cardiology.
• Medical oncology.
• Radiation oncology.
• Sleep management – sleep apnea treatment/supplies.
• Musculoskeletal advanced procedures.
• Musculoskeletal therapies.

Together, we’re committed to making appropriate coverage decisions regarding prior-authorized requests for your patients’/our members' healthcare that meet their medical needs and the terms noted above. We recognize that you as their provider are the experts in managing their healthcare needs. We share with you the common goal of ensuring the patient/member receives quality healthcare that’s effectively managing their condition and meets the evidence-based standard-of-care guidelines and policies. We also strive to make information available to you that’ll assist you in navigating through the necessary steps of the prior authorization, admission notification and inpatient concurrent review processes. We support our members with our care coordination team, who’ll assist in coordinating our members through various levels of care.

Most prior authorizations can be requested electronically through the FirstCarolinaCare Provider Portal.

Register on the Provider Portal here.

Medical Management: Utilization Review and Prior Authorization

Overview

FirstCarolinaCare has a comprehensive Medical Management program administered by the Population Health/Medical Management Division (MMD). The FirstCarolinaCare Utilization Management Coordinators (UMCs) and care coordinators are accountable for the activities outlined in the Program Scope and Processes. These individuals work directly with the primary care providers, specialists and other providers in the FirstCarolinaCare provider network responsible for coordinating the care of our members. Selected physician medical directors provide direct utilization management, as well as oversight for utilization and care coordination across the entire plan.

Purpose

The MMD is committed to ensuring that the care delivered to our members is of the highest value (Value = (Quality + Service)/Cost). FirstCarolinaCare is committed to providing members with efficient, cost-effective and quality healthcare coverage. FirstCarolinaCare employees never encourage decisions that result in underutilization of care. We do not give financial inducements or set quotas for issuing denials of coverage or care; nor do we keep statistics identifying individual providers and their denial rates. Utilization decisions made by our medical directors, Utilization Management nurses, pharmacy coordinators and pharmacists are based only on appropriateness of care and service, and the existence of coverage. There are no incentives, financial or otherwise, to encourage barriers to care and services.

Medical Necessity Review/Criteria

The UMCs respond to coverage requests by obtaining all necessary clinical information, researching benefit plan descriptions and applying established medical necessity criteria. The MMD uses clinical guidelines from nationally respected vendors, such as InterQual and eviCore, which are based on best practice, clinical data and medical literature. Where vendor guidelines are incomplete or absent, internal medical policies are developed by the Medical Policy Committee and approved by the Medical Directors Committee. InterQual and eviCore clinical guidelines, and internal medical policies, are available on the Provider Portal.

Each case is evaluated, and the established medical criteria appropriate to each case are applied. Individual patient circumstances and the capacity of the practitioner and provider delivery systems are considered. This includes the consideration of alternate settings when needed. Factors such as age, co- morbidities and complications, progress of treatment, psychosocial situations, and home environment (when applicable) are factors that are reviewed when applying criteria. You can greatly reduce the time it takes for a review to be completed by supplying complete medical information and attaching all supporting clinical documentation when submitting a request for coverage. Also, monitor and promptly respond to requests for missing or additional information.

Utilization Management

Prior Authorization Review

Prior authorization is a screening review process to ensure the medical necessity of selected services. This review provides for an enhanced matching of patient need with medical necessity and the appropriateness of the location of service. Clinical documentation to support the medical need of the service must be submitted with the review request. UMCs perform the prior authorization function and any request that falls outside the approved guidelines is forwarded to a medical director for review and coverage determination. Prior authorization occurs prior to the delivery of service, and is subdivided into four categories:

1. Screening of selected elective services (e.g., inpatient rehabilitation facility or a skilled nursing facility).
2. Screening of selected procedures/diagnostic testing that are on the prior authorization list.
3. Screening of all physician referral requests to out-of-network providers for plans with or without out-of-network benefits, if the member is requesting in-network coverage.
4. Screening for other medical services, such as durable medical equipment or other specified services, to ensure clinical appropriateness.

Admission review is conducted within one (1) business day of being notified of the admission, so the necessity of an admission can be determined and concurrent review can be initiated. Notification of admission is required within 24 hours or the next business day.

Inpatient Concurrent Review (ICR) for Medical, Surgical and Behavioral Healthcare Admissions

Inpatient concurrent review (ICR) is a process conducted by assigned UMCs and medical directors to assess the need for continued inpatient care for a member who’s been admitted to a hospital, skilled nursing facility (SNF), acute inpatient stay in a behavioral healthcare facility, or physical rehabilitation facility. The UMCs will communicate the required frequency of medical necessity reviews, and they’ll use clinical notes provided by the facility. This review is performed to determine if the level of care continues to be medically appropriate or if care can be transitioned to a lower level of care.

Discharge planning and coordination of care by the UMC begins upon admission. Individual reviews are performed to analyze each case for special needs and to consider availability of local healthcare resources. UMCs and the facility discharge planner work with the attending physician to ensure the member receives care at the most appropriate level. When warranted, the Inpatient Care Coordinator meets with the patient and family members as early in the hospital stay as appropriate to discuss potential healthcare needs and coverage (this may not be indicated for short uncomplicated hospitalizations). If the member has complex issues or healthcare needs, they are referred for care coordination for evaluation and potential enrollment. In circumstances where the member’s benefits have been exhausted but medical needs still exist, the care coordinator will assist the member by providing information about other resources. This may mean informing the member or family about ways to obtain continued care through other sources such as community and government agencies. A referral to care coordination is also made.

Behavioral Health & Substance Use Disorder

The behavioral health components of the UM program are limited to inpatient review, out-of-network referral review, and selecting and updating medical necessity criteria. Behavioral health practitioners are involved in the UM program in a variety of ways. Practitioner involvement includes a medical director who’s board certified in adolescent and adult psychiatry, and consultation with practicing psychiatrists and addiction medicine physicians associated with Carle Physician Group and with a company that specializes in behavioral health reviews. We follow the American Society of Addiction Medicine (ASAM) guidelines for substance use disorders.

Skilled Care

FirstCarolinaCare requires prior authorization for a skilled level of care at a skilled nursing facility (SNF). Utilization Management Coordinators will continue to review the beneficiary’s condition and progress periodically at the SNF during the covered skilled stay and work with staff at the SNF to monitor the beneficiary’s condition. Reviews are conducted by phone and may also occur on-site at the facility. FirstCarolinaCare staff will issue the appropriate communication to the beneficiary when services are ending. Appeal rights will also be provided to the beneficiary. SNFs are required to provide all requested clinical updates and pertinent information regarding the beneficiary’s progress and discharge planning as requested by FirstCarolinaCare Medical Management.

Denial of Coverage or Authorization

If the requested or received service does not fall within the scope of the approved MMD criteria, the case is referred to a medical director for review. The medical director reviews all the medical information to make a coverage determination, and additional information is requested if needed. The medical director may contact the requesting physician to discuss the case further. When necessary, the medical director confers with a specialist. After review of the case facts, the medical director makes a coverage determination of approval or denial, using their medical judgment, experience and skill, as well as professionally recognized medical standards for treatment. For all denials, the member, the member’s representative and the requesting practitioner are notified in writing of the determination. The denial notice includes the rationale for the denial, the criteria used to make the determination and the appeal process.

Requests for benefits that clearly fall outside the member’s benefit package may be denied by the UMC. Any denial decisions for services that are, or that could be considered, covered benefits are determined by the medical director as previously described. All appeals are forwarded to the Member and Provider Resolutions Unit for processing and resolution.

Turnaround Time Frames for Coverage

When it comes to reviewing requests, our dedicated staff work efficiently to provide decision notifications. Below you’ll find our goal time frames for notifying you of coverage decisions. Our Medical Management Division (MMD) adheres to the Centers for Medicare & Medicaid Services as well as the Department of Labor (DOL) and state Department of Insurance (DOI) regulatory requirements and takes into account the medical urgency of each member’s condition. Please note that additional time (within DOL and DOI/state maximum time frames) will be taken if needed to perform a comprehensive review.

Types of Requests:

Standard (Non-Urgent) Preservice Requests - Our goal is to provide coverage decisions within five (5) business days of receiving a complete request that contains all the necessary medical documentation, unless there’s a regulatory standard that requires a shorter turnaround time.

Urgent Preservice Requests - For urgent preservice requests, our goal is to provide coverage decisions within one (1) business day of receiving a complete request, but we may take up to the 48 hour or 72 hour (Medicare Advantage) regulatory time frame if the case requires more intensive review. Please mark requests “urgent” only when there’s an urgent medical need to receive the services within the shortened time frame. “Urgent” should not be used for scheduling conveniences. Marking requests “urgent” that are not truly urgent results in processing delays for all requests. Urgent care is defined as any request for care or treatment with respect to which the application of the non-urgent time period for making a determination could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function, based on a prudent layperson’s judgment, OR in the opinion of a practitioner with knowledge of the member’s medical condition, when the application of the non-urgent time period for making a determination would subject the member to severe pain that cannot be adequately managed without the care or treatment that’s the subject of the request. Emergency services are reviewed retrospectively for medical necessity.

Please submit complete requests. Supporting documentation is always necessary in making coverage decisions. If you submit inadequate information, the review will take longer to complete and your answer will be delayed. In some cases, we may have to initiate a review extension by sending you a letter explaining what specific information is needed and the time frame for the extension (the FirstCarolinaCare member will also receive a copy of this letter).

You can greatly impact the time it takes for a review to be completed by supplying complete medical information when submitting a request for coverage, and by promptly responding to requests for additional information should the original request be missing something.

Appeals

• Medically related appeals concern a prospective (preservice) denial or noncertification or retrospective (post-service) denial of coverage when the treatment or service doesn’t meet the FCC medical necessity requirements.
• Non-medically related complaints encompass eligibility, benefit coverage and/or procedure issues.

To start an appeal:

• Call the Member Services number on the member's health plan ID card.
• For urgent appeals, call us at (800) 500-3373.
• Fax appeals to (217) 902-9708.
• Mail us in writing to:
  FirstCarolinaCare Insurance Co.
  ATTN: Member Relations
  3310 Fields South Drive
  Champaign, IL 61822

Care Coordination Programs

The care coordination programs are primarily telephonic and conducted on an outpatient basis. Care coordination integrates the health team by including the member, family, physician and ancillary providers in conjunction with the health plan. A team effort between all the involved parties allows for better continuity, consistent treatment planning and transition of care from one level to another when indicated. Care coordinators assess, coordinate and – in certain medical situations – assist with the authorization of services for identified high-risk members. This coordination of care includes efforts to identify opportunities for cost effective treatment while maintaining or improving the quality of services available under the member’s plan.

The care coordination program focuses on assisting with coordination of services to ensure the member is receiving the right care, at the right time and in the right place. This includes acting as a liaison among multiple care providers, members and family. Another focus is educating members on their disease process and lifestyle changes that could impact or slow down the progression of their disease. The care coordination program includes, but is not limited to, serving those with the following conditions, diseases or high risks:

• Acute myocardial infarction.
• Cancer.
• Diabetes.
• Transplants.
• Cardiac and/or lung disease.
• Congestive heart failure.
• Kidney failure/end-stage renal disease.
• Multiple/repeat admissions or emergency department visits.
• Multiple chronic illnesses or chronic illnesses that result in high utilization.
• Neurological syndromes.
• Pediatric anomalies.
• Traumas.
• Wounds.

How to Get More Information

If you have questions about the status of a review or other Medical Management processes, or would like to refer a member to our care coordination program, call FirstCarolinaCare Customer Service at the following:

Customer Service Phone Numbers

FirstMedicare Direct - Sandhills: (877) 210-9167
For Medicare Advantage members living in Moore, Montgomery, Hoke, Richmond, Scotland, Lee, Johnston, Harnett, Cumberland, Robeson and Chatham counties.

FirstMedicare Direct - Triangle: (877) 749-3356
For Medicare Advantage members living in Wake county.

New Hanover Health Advantage: (855) 291-9336
For Medicare Advantage members living in Brunswick, New Hanover, and Pender counties.

FirstCarolinaCare - Commercial: (800) 481-1092
For all Commercially Insured members.

Monday – Friday, 8 a.m. to 5 p.m. After normal business hours, you may leave a message at this number and it’ll be returned the next business day.

To request prior authorization, please log on to FirstCarolinaCare.com/Providers. One logged in, you can check member prior authorization lists, search particular codes to find out if prior authorization is required and submit prior authorization requests.

Prior Authorization Submission Provider Tips

Tips for Timely Prior Authorization:

Please provide us a phone number and fax number where we can reach both you and the “referred-to” provider.

• A direct phone number and fax number (instead of a call center number) can help us reach your staff if we need additional information or wish to discuss your request with you.
• Submit Clinical information along with the initial request.

Please provide your NPI and Tax ID number, as well as the NPI and Tax ID number for the referred-to provider. Both numbers help us eliminate confusion and quickly determine participation status of our providers.

We may reach out to your office for additional clinical documentation. Please respond as soon as possible to avoid delays in the review.

Tips for submitting complete clinical information and responses:

• Submit current clinical documentation, avoiding outdated records.
• Pay close attention to including clinical documentation that supports the request, avoiding duplicative documentation or a large chart with unnecessary or inappropriately related PHI.
• Pay close attnetion to providing complete responses to specific clarifying questions from our UM department.
• If no response or no additional clinical information is received near the end of the regulatory time frame, we'll make the decision based on the information originally received with the request. If no Clinical was submitted, then the case will be denied after the regulatory timeframe has expired. If there's no additional information that can be provided, please contact us immediately so we may proceed with the decision.
• For requests involving medication, enteral formula, supplies, or durable equipment, please include a current, valid prescription.

Inpatient Hospital Facility Notification and Concurrent Review

Please notify us of any hospital admission by phone, fax or email within 24 hours or the next business day, even if there’s an authorization on file for a procedure.

Please include the following information with your notification:

Provider Information:

• Facility’s name and NPI number.
• Admitting physician’s name and NPI number.
• Utilization review phone number.
• Utilization review fax number.

Member (Patient) Information:

• Member name.
• Member identification number.
• Member date of birth.
• Date and time of admission.

Other Pertinent Information:

• If this was an admission through the emergency department, please include this information in the notification.
• Please note if this is an admission for behavioral health or substance abuse. Please specify the category of admission. For example, intensive outpatient (IOP), partial hospitalization (PHP), residential or full inpatient.
• Please note if this is an admission for medical, surgical or obstetrics. If obstetrics, please include the date and type of delivery, with sex of newborn.
• Include the primary diagnosis (ICD-10) code.

How to Submit an Inpatient Notification of Admission:

For FirstCarolinaCare providers, please fax the initial request with clinical to (866) 896-1941. Additional information for FirstCarolinaCare providers can be found at FirstCarolinaCare.com/Providers.

How We Determine Level of Care and Coverage for Inpatient Stays:

We work closely with the hospital care team performing periodic concurrent review to evaluate level of care, coverage and clinical progress, and we assist with discharge planning. Concurrent review may be done by phone, fax or review of the electronic medical record, where appropriate.

The concurrent review process includes:

• Collecting information from the care team about the patient’s condition and progress.
• Determining coverage based on this information.
• Informing everyone involved in the patient’s care about the coverage determination.
• Identifying a discharge and continuing care plan early in the stay.
• Assessing this plan during the stay.
• Identifying and referring potential quality-of-care concerns and patient-safety events for additional review.
• UM Coordinators identify our members for referral to our care coordination program, which includes – but is not limited to – helping those members who have the following conditions, diseases or high risks:
  • Acute myocardial infarction.
  • Cancer.
  • Diabetes.
  • Transplants.
  • Cardiac and/or lung disease.
  • Congestive heart failure.
  • Kidney failure/end-stage renal disease.
  • Multiple/repeat admissions or emergency department visits.
  • Multiple chronic illnesses or chronic illnesses that result in high utilization.
  • Neurological syndromes.
  • Pediatric anomalies.
  • Traumas.
  • Wounds.
  • Maternal health.
  • NICU.
  • Complex pediatrics.

How does the FirstCarolinaCare Utilization Management team support our hospitalized patients/members?
The UM Coordinator/Concurrent Review Nurse and Social Service support staff is available to assist with discharge planning by providing a list of in- and out-of-network resources as needed. A list of in-network skilled nursing facilities, LTACHs and inpatient rehab facilities can also be found on our website here. We also may refer our patient/member to our care coordination program after discharge.

How will FirstCarolinaCare communicate with providers around inpatient stays?
Utilization Management Coordinators will notify providers of bed days approved and the next concurrent review date via phone, fax or letter. All notifications of medically unnecessary days will be sent to the provider via letter.

Post-Acute Care

(SNF, Inpatient Rehabilitation Facility, Long-Term Acute-Care Hospital)

Do I need to submit a prior authorization before a patient/member is admitted to a skilled nursing facility, inpatient rehabilitation unit or long-term acute-care hospital?
Yes, prior authorization is needed before admission to determine if the medical necessity is met. Our team will continue to review the care of our patient/member throughout their stay to follow their progress and determine if skilled care is still appropriate.

How do I submit a request for post-acute care (SNF, inpatient rehabilitation facility, long-term acute- care hospital)?
For FirstCarolinaCare members, please fax the initial request with clinical to (866) 896-1941. Additional information for FirstCarolinaCare providers can be found at FirstCarolinaCare.com/Providers.

How does FirstCarolinaCare support a member admitted to a skilled nursing facility?
FirstCarolinaCare Utilization Management nurses and social workers closely collaborate with the care team at the skilled nursing facility. As our members approach the point where they’ll no longer require skilled care, our team communicates with the care team about progress, discharge planning and alternate levels of care where appropriate. Prior to coverage ending, we provide 48 hours of notice for additional planning.