Utilization Management
Utilization Management (UM) helps us work with your doctors to give you the right care at the right time, and in the right setting. We care about your health and wellness and want to make certain the care you receive is of high quality and value.
If you are provider, view utilization management information for providers here.
Prior Authorization and Notification of Admission
What is prior authorization?
Prior authorization is a tool used within Utilization Management. It’s a screening review process of select medical care or services before you get that care. You and your provider will decide what healthcare you need and our review does not take the place of the advice from your provider. Our prior authorization review allows us to work closely with your provider, partnering so you receive high-value care. As stewards of your healthcare resources, prior authorization is a check and balance, helping to make sure the care you receive is safe, effective and affordable.
When we review requests for prior authorization, we use the medical information submitted by your provider, your specific plan coverage and benefits, and clinical review criteria and standards that are objective and evidence-based. This is criteria that your provider knows and trusts and is widely recognized. Qualified health professionals, such as doctors and nurses, review prior authorization requests and make decisions. Our process supports fair and timely reviews and can reduce costs by making sure there isn’t another affordable treatment that’s equally effective or other opportunities for you to receive care in your provider network.
Who requests prior authorization?
Physicians and other healthcare providers are responsible for requesting prior authorization with us or with our partner, eviCore Healthcare.* Before any procedure or lab work, it’s a good idea to check with your provider to see if they’ve contacted us to verify if prior authorization is needed.
You can check your benefits, coverage and which services require prior authorization – so you know what’s required before you have services performed or appointments made. Log into your member portal at hally.com or call the number on your health plan ID card if you’d like more information, or if you’d like a copy of your coverage documents mailed to you. To locate providers in your network, check the Provider Directory here.
How can I request prior authorization?
Providers are the ones that initiate the authorization process. Check with our Customer Solutions department by calling the number on your health plan ID card. They can see if your provider has requested prior authorization before you get any services.
*FirstCarolinaCare partners with eviCore Healthcare for certain prior authorization services.
If your provider has not requested prior authorization, our Customer Solutions team can help you begin the process.
How does the prior authorization process work?
FirstCarolinaCare, or our partner eviCore Healthcare, will review the requested service submitted by your provider using evidence-based criteria to determine if it’s medically necessary.
To complete a prior authorization request, here’s what we’ll need:
- Your name, health plan member ID number and date of birth.
- Your provider’s name, address, phone number and National Provider Identifier (NPI).
- Information about your health condition (your medical records from your provider).
- The treatment plan your provider is recommending, including any diagnosis and procedure codes.
- The date you’ll need to receive the service and for how long.
- The place you’ll be treated.
Prior authorization may be required for some outpatient services such as planned elective surgeries, durable medical equipment, specialty visits, certain inpatient services or post-acute care like admission to a skilled nursing facility.
Prior Authorization for Inpatient Acute and Post-Acute Care in a Facility
Notification of Your Hospital Admission and Your Stay
Utilization Management also takes place during hospitalization. Acute-care hospitals are responsible for notifying us of your admission for inpatient services within 24 hours of your admission, even if you have an authorization for an elective surgery or treatment already on file. We’ll work closely with the hospital care team to collect information on your condition and progress, and determine ongoing coverage based on this information. When you’re in the hospital, we’ll help make sure you get the right level of care at the right time. Throughout your stay, our Utilization Management nurses, social workers and physician medical directors will assess and help with your care, your discharge from the hospital, and beyond. Our goal is for you to receive safe and high-quality care. To help you navigate your care after you go home, we’ll identify whether you might benefit from one of our covered case management care coordination programs, such as care transition intervention, health coaching and disease management, specialty or complex care coordination, or something else.
Emergency Services
If you should require emergency inpatient services, the facility you’re admitted to should also notify FirstCarolinaCare of your admission within one business day.
Check with our Customer Solutions department by calling the number on your health plan ID card. They can see if your provider has requested prior authorization before you get any services.
If your provider has not requested prior authorization, our Customer Solutions team can help you begin the process.
Prior Authorization for Post-Acute Care in a Facility
Post-acute care is a special type of care that you may need following a stay in the hospital. The care focuses on helping you regain your level of function you need to go home. Post-acute care can take place at a skilled nursing facility, long-term acute care hospital or an acute inpatient rehabilitation facility. Your discharging provider at the hospital will work with you to determine your options for care and at which facility you wish to receive your care. Your provider is responsible for sending us a request for prior authorization before you’re admitted for this type of post-acute inpatient care. Once your post-acute care is approved and you’re admitted for care, we’ll work together with your provider to stay informed of your care needs and help plan the next steps when you no longer require post-acute care.
If you received skilled care in a skilled nursing facility and no longer need skilled services, you may return home independently, return home with home health services, seek a residence at an assisted living center or choose to remain in a nursing facility with custodial care. Custodial care is nonskilled personal care that doesn’t require daily skilled medical services. Some examples of custodial care include help with bathing, dressing, eating, using the bathroom, or getting in and out of bed. Although your provider might recommend custodial care, if it’s the only care you need, in most cases, this type of long-term care is not covered by Medicare or your health plan.
To assist you with navigating your healthcare, we’ll connect you with our Hally® care coordinators at no cost. This is a free service that we provide to aid you in your health. Care coordinators work with you, your doctors and your nurses to help you get the most out of your coverage and help you manage your health conditions. If you plan to receive care in a larger, tertiary care center or with a provider who’s out of your network, our care coordinators can help you with your journey. To learn more about Hally health and care coordination click here.
Appeals
If you have a complaint or are unhappy with coverage for care or a service being denied, in certain situations, you have the right to file an appeal to review the denial again.
To start an appeal:
- Call the Member Services number on your health plan ID card.
- For urgent appeals, call us at (800) 500-3373.
- Fax us at (217) 902-9708.
- Mail us your appeal in writing to:
ATTN: Member Relations
FirstCarolinaCare
3310 Fields South Drive
Champaign, IL 61822
Notes
For the purposes of this policy, "coverage" means either the determination of (i) whether or not the particular service or treatment is a covered benefit pursuant to the terms of the particular member's benefits plan, or (ii) where a provider is required to comply the FirstCarolinaCare Utilization Management programs, whether or not the particular service or treatment is payable under the terms of the provider agreement.
This is a summary of the Prior Authorization and Notification Program and is not meant to be comprehensive. Please refer to your member materials for details.
Utilization Management FAQs
Questions About Prior Authorization and Appeals
- How do I know if I need prior authorization?
To view your prior authorization lists, log into your member portal at hally.com and click “Authorizations” in the banner. See the section, “Do I Need a Prior Authorization?”
You can also contact our Customer Solutions team by calling the number on your health plan ID card or by email at FCCCustomerService@FirstCarolinaCare.com.
- How long does it take for an authorization request to be decided?
We strive to meet all regulatory requirements and have dedicated nurses, social workers and physicians reviewing requests.
Some requests submitted online to FirstCarolinaCare or with our partner, eviCore Healthcare, can be auto-approved within minutes if medical necessity criteria are met during the submission process. At FirstCarolinaCare, 75% to 80% of prior authorizations are automatically processed.
Our turnaround time is dependent on providers timely submitting all needed clinical information at the time of the request. There may be situations where additional time is needed.
- What happens if my authorization request is urgent?
State and federal regulations, and our accrediting body, ask us to use and follow their definition of situations that are considered medically urgent. We’ll expedite requests if we find that applying the regular time frame could seriously jeopardize life or health of our member or our member’s ability to regain maximum function. Scheduling or appointment timing is important to you and your provider. Our team is dedicated to reviewing your request in a timely manner, even when the request does not meet medical urgency.
- Who approves or denies my authorization request?
Qualified health professionals such as nurses, social workers and physicians review prior authorization requests. Any decisions that may not be favorable to you are reviewed and decided by a physician medical director.
- I received a letter addressed to my provider asking for additional information. What do I do?
Sometimes we receive incomplete information or may need additional clinical information from your provider. We’ll fax a letter to your provider asking for this information and send a copy, to you, simply to keep you informed of the status of the request.
You’ll not need to take any action; we’ll expect your provider to send us the needed information. Should you have the specific information being requested or have any questions, please contact our Customer Solutions team.
- How will I be notified of the authorization decision?
You’ll be notified in writing of any unfavorable decision (denial) and may receive a phone call from our Utilization Management team before the letter arrives. You may also receive correspondence or a call from our partner, eviCore Healthcare, on behalf of FirstCarolinaCare.
- Who should I contact if I have questions about my authorization?
Our Customer Solutions team can help answer any questions about your authorization or the process. Please contact the number on your health plan ID card or email FCCCustomerService@FirstCarolinaCare.com.
- Where can I find the clinical review criteria that was used to determine my authorization decision?
FirstCarolinaCare and eviCore Healthcare criteria can be found here: Medical Policies.
FirstCarolinaCare uses internally developed medical policies based on evidence-based research and guideline standards, InterQual criteria, and American Society of Addiction Medicine (ASAM) criteria.
- How do I appeal an authorization denial and have the denial reviewed?
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 us at (217) 902-9708.
- Mail us in writing to:
FirstCarolinaCare Insurance Co.
ATTN: Member Relations
3310 Fields South Drive
Champaign, IL 61822
- My prior authorization request was denied, I appealed and now my care is approved. What happened?
Our Utilization Management healthcare professionals work to make certain you receive the right care at the right time and in the right setting. When denial decisions are overturned and approved during the appeal process, it’s often because additional clinical information from your provider was not submitted or available to our team when we were making the original decision. This additional information we receive later may show the service is medically appropriate.
Out-of-Network or Nonparticipating Providers/Facilities
- Do I need a prior authorization to visit a provider who’s not in my network?
This will depend on your plan. We recommend you check your provider directory or contact our Customer Solutions team by calling the number on your health plan ID card.
Generally:
- If your plan has out-of-network benefits for nonparticipating providers, a prior authorization for a referral to see the provider is not required.
- If your plan does not have out-of-network benefits, any non-emergent and out-of-network services or benefits will require a referral from a plan physician (a primary care physician (PCP), in-network specialist or attending physician) and prior authorization from FirstCarolinaCare.
Member Frequently Asked Questions (FAQ)
- I received a letter from FirstCarolinaCare stating that my authorization needs additional information. Do I need to take any action?
No, we have contacted your provider for this information and have sent you a copy of the letter to keep you informed of the status. At the time of the request for your service, we ask for your provider to submit clinical records supporting the service requested.
- Our in-network providers can upload the information to our Provider Portal.
- Out-of-network providers must contact eviCore directly at (877) 872-4161 to initiate a request for prior authorization, which they manage.
For all inpatient Notifications of Admission – and post-acute skilled nursing facility, inpatient rehabilitation facility and long-term acute care facility – the provider may submit the request via fax, with clinical information, to Utilization Management at (866) 896-1941.
- How will I know when my prior authorization request has been completed?
We work closely with your provider’s office to keep them informed of the status of the prior authorization request, and your provider’s office may be in contact with you once it’s completed. If your service is denied, you’ll receive a denial letter with specific information regarding the reason for denial and information on the appeal process.
Questions for Post-Acute Care
- Why did my coverage end at the skilled nursing facility?
When you enter post-acute level of care, planning for your safe discharge is started on the day you’re admitted to a skilled nursing facility. As you get better, make progress and approach the point where you no longer require skilled care, our nurses and social workers will be in close communication with your care providers to help with discharge planning and discuss alternate levels of care when needed.
- My Medicare benefit says I receive 100 days of skilled nursing coverage. Why was my coverage denied?
The Medicare 100 days of coverage applies to daily skilled services you might need. It’s important to use these days only when your clinical situation calls for daily skilled services. FirstCarolinaCare helps you manage those days so you have them when you really need them.
- Do I need a prior authorization before I’m 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 based on your clinical situation. Our team will continue to review your care throughout your stay to follow your progress and determine if skilled care is still appropriate for you.