How Utilization Management Works

In the event you require services not available in your Primary Care Physician's office, your doctor may wish to refer you to a Specialist for additional testing, evaluation or treatment. Some tests and diagnostic procedures require prior authorization, which means your doctor or the specialist may need to obtain pre-approval from Medcore HP prior to performing the tests or procedures.

Requests for Referrals

A referral to a specialist within Medcore HP's local network of physicians and providers does not require prior approval from Medcore HP. Your Primary Care Physician can make the referral directly and arrange for your appointment with the specialist.

Under most circumstances your Primary Care Physician will refer you to doctors and providers within Medcore HP's local network. However, should you need services not available within Medcore HP's local network, your Primary Care Physician will need to fill out a form called a Referral Authorization Request and forward it to Medcore HP's Utilization Management Department for review by a special committee of doctors.

The Referral Authorization Request is reviewed using specific criteria for determining medical necessity, based on current information about your medical condition and treatment provided by your doctors. A decision is made to approve or deny the request, or if a decision cannot be made based on the information provided, additional information may be requested before a final decision is made.

Requests for Elective Procedures/Surgery

Some elective procedures and surgery (procedures that are not-considered urgent or an emergency) require prior authorization and must also be pre-approved by Medcore HP prior to scheduling the surgery or procedure. Your doctor will need to fill out a form called a Referral Authorization Request and forward it to Medcore HP's Utilization Management Department for review by a special committee of doctors.

The Referral Authorization Request is reviewed using specific criteria for determining medical necessity, based on current information about your medical condition and treatment provided by your doctors. A decision is made to approve or deny the request, or if a decision cannot be made based on the information provided, additional information may be requested before a final decision is made.

Approval of a Referral Authorization Request

You will be notified the health plan when a requested authorization is approved, and your doctor may then proceed to schedule the requested appointment, procedure or surgery.

If Utilization Management denies an authorization request, you have the right to appeal. Your doctor may also appeal the decision on your behalf by submitting a detailed explanation of the medical necessity of the request, and supplying supporting medical information.

If the appeal is denied, you and/or your doctor may further appeal the decision. (Please see Appeals and Grievances). An Appeals Committee that consists of representatives who were not involved in the first level appeal decision will review the appeal request. At least one practitioner, in the same or similar specialty that typically manages the medical condition, procedure, or treatment will be involved in making the appeals decision.

Once a decision is made, the Appeals Committee will send written confirmation of its decision to your home and to your doctor.

How to Obtain Criteria or File an Appeal

The Appeals Committee uses specific criteria to make decisions regarding the medical necessity of an authorization request. You are entitled to a copy of the criteria used by the committee to review your request for a specific service. To obtain criteria or file an appeal, please contact Medcore HP's Member Services Department at (800)-320-5688 (TTY/TDD 800-258-6810) and a Member Services Representative will assist you.

For additional information related to appeals and grievances please see "Appeals and Grievances".