Utilization Management

Understanding CHP's Health Care Decision-making

CHP reviews medical literature and seeks the input of appropriate specialists to develop clinical review standards for coverage of certain health care services. These clinical guidelines are available to members and participating providers. CHP's participating physicians use the clinical review standards to help determine when a member needs health care services and supplies, and which services and supplies are suitable. A primary care physicain or participating provider may request that CHP review, for coverage purposes, whether a member meets clinical standards for a specific service or supply. CHP may also proactively evaluate specific services or supplies to determine coverage by the member's plan. The requested services and supplies must support the diagnosis and treatment of the member's condition and standards of good medical practice. The review process may be pre-service (before services are provided), concurrent (based on an urgent request to continue services), or post-service (after services are provided).

If you have questions about utilization management procedures, decisions or your benefits, you can contact our Member Services Department at (850) 383-3311 or toll-free at 1-877-247-6512, Monday through Friday from 8:00 am through 5:00 pm. The TDD number for the hearing impaired is (850) 383-3534. If you call after hours or on a weekend, you can call (850) 383-3333 or toll-free (800) 390-1434. The after-hours number for the Florida State Relay, for the hearing impaired, is (800) 955-8771.

CHP safeguards confidential information and makes disclosures only when allowed under state and federal law, including HIPAA. Information used in the decision-making process is protected by CHP staff members who must use the information.

CHP's policy statement for utilization management decisions:

1. Utilization management decisions are based only on the appropriateness of care and services according to the clinical standards, and the existence of benefit coverage.
2. CHP does not reward reviewers or provide financial incentives to deny coverage or care.
3. CHP does not offer incentives to encourage decisions that result in underutilization.

A member, physician, or a person authorized by a member may request a re-evaluation of a utilization management decision as follows:

• By sending to CHP's Grievance Department a written request for reconsideration, which is known as a grievance. Staff collects any necessary documents, and the member request is reviewed by a group of senior managers and physicians. CHP notifies the member in a timely manner of the review group's decision.
• By requesting an expedited grievance decision. Expedited decisions are those made when a delay in a grievance decision for care that has not occurred would harm the member's health. A call to Member Services at (850) 383-3311 alerts CHP to make an expedited grievance decision. Staff will then notify the member when the decision has been made.
• By asking for an evaluation by an organization outside of CHP if dissatisfied with the grievance decision. An "Independent review organization" which has no financial or business ties to CHP, will then evaluate the request. Members pay nothing for independent reviews, and CHP must accept decisions made by independent review organizations. The letter that notifies the member of the grievance decision explains how to request an independent review.
• Click here for additional information about procedures related to grievances.

CHP regularly reviews new medical technologies (drugs, procedures and devices) for coverage. Members and providers may ask at any time for consideration of new technology. To make decisions, CHP's medical director and consulting experts investigate many sources, such as the Technology Center Clearinghouse of the Blue Cross Blue Shield Association, Agency for Health Care Research and Quality, Medicare manuals, medical journals, and government regulatory bodies. The standards for approval include:

• final acceptance by the proper government regulatory body
• testing that shows a positive effect on health
• improved health outcomes at least as helpful as any recognized option
• improved outcomes outside the investigational setting

Referrals and Authorizations

It is important to understand the difference between a referral and an authorization, and how to obtain each one.

Referral is the process of sending a patient to another practitioner (ex. specialist) for consultation or a health care service that the referring source believes is necessary but is not prepared or qualified to provide. Your primary care physician will refer you to a participating specialist or a health care service provider if he or she cannot personally provide the care you need. Many referrals do not require an authorization number.

Authorization, also known as precertification, is a process of reviewing certain medical, surgical or behavioral health services to ensure medical necessity and appropriateness of care prior to services being rendered. The review also includes a determination of whether the service being requested is a covered benefit under your benefit plan. Authorizations are only required for certain services. Your physician will submit authorization/precertification requests electronically, by telephone, or in writing by fax or mail. If approved, an authorization number is then generated by Capital Health Plan and is available to you via CHPConnect. If the requested service is not authorized, the member and provider are notified in writing with the specific reasons for the denial.

Authorization numbers are NOT required for the following; they can be completed with a referral or an order from your Primary Care Physician or Specialist:

• Most office visits and office based procedures for local network participating practitioners [1]
• Mammograms
• Ostomy supplies obtained from Medical Care Products
• DME and oxygen obtained from American Home Patient Care (in the service area) and Desloge Home Oxygen & Medical Equipment
• Big Bend Hospice home based services
• DaVita dialysis services [2]
• Most Physical Therapy and Occupational Therapy obtained from TMH outpatient Rehabilitative Services and the Center for Orthopedic and Sports Physical Therapy
• Most outpatient diagnostic imaging at local participating radiology locations (TDI, THI, Radiology Associates)
• Services rendered in a medical emergency

Authorization numbers ARE required for the following:

• All inpatient services
• All outpatient hospital and facility based surgery
• All non emergency services received outside CHP’s service area, including out of area contracted practitioners (ex. Shands)
• All services related to the mouth and/or teeth
• All Plastic Surgery specialty services
• Speech Therapy
• Back (lumbar) and neck (cervical) MRIs
• All home health care services (except hospice care as listed above)
• Services that may be investigational or outside the realm of accepted mainstream medical care.
• All services/procedures that require review against Capital Health Plan's clinical criteria [3]

[1] Contact Capital Health Plan’s Member Services Department for further information on which local participating practitioners still require an authorization for services

[2] Dialysis services received outside of Capital Health Plan’s service area may necessitate receiving services from a facility other than DaVita – you should work with your local DaVita facility to coordinate these services prior to leaving the service area.

[3] You and your Primary Care Physician have access to Capital Health Plan’s Utilization Management clinical criteria through CHPConnect. You may also request a list of Capital Health Plan’s clinical criteria by contacting the Member Services department.