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Hometown Health Utilization Management Program Requirements
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Physicians , health care professionals and ancillary providers are responsible for prior authorization for certain planned services . These requirements vary by the member ’ s plan . In general , the member ’ s Evidence of Coverage , Summary Plan Description , and Summary of Benefits are available on Link in the Eligibility section and outline the specific plan ’ s prior authorization requirements . Failure to comply with the program requirements that are outlined in this section and in the member ’ s specific benefit plan may result in claims being denied in whole or in part , and as required and specified in your contract , may result in the member being held harmless for all or part of the costs of the services .
The Healthcare Utilization Management Department coordinates requests for referral authorization and clinical utilization management of members to promote medically necessary high-quality care in an optimal setting . National guidelines provided by MCG and Hayes Technology Assessments , are used to determine medical necessity and the appropriate level of care for services . CMS policies are also used to review requests for Senior Care Plus products . URAC and NCQA certified medical review companies are consulted on a case-bycase basis for questions or appeals that require same specialty review . Copies of specific guidelines or policies are available on request from the Healthcare Utilization Management Department .
Prior Authorization Requirements
Providers are responsible for obtaining prior authorization for services that require prior authorization by the plan , regardless where the services are to be performed , office , hospital or ambulatory center . Facilities are responsible for confirming the prior authorization is on file at Hometown Health prior to the date of the services . Services that are provided by the facility , like radiation therapy or infusion services must be prior authorized by the facility . The facility would also be held accountable for obtaining prior authorization for services that require an authorization per the member ’ s benefit plan and that are rendered by hospitalbased physicians . A minimum of five business days in advance of the service date is required for non-urgent or emergent services to be reviewed for prior authorization . If the service is scheduled less than five business days in advance , the facility will give notice at the time the service is scheduled , so that the service can be reviewed for coverage . Hometown Health will not perform retrospective authorization reviews beyond 7 days .
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