Administrative Policy effective January 1, 2020

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Retro Review Process Update for Essential Plan

Audience: Retro Review Facilities

Our pending transition to CareAdvance Provider, the electronic preauthorization tool that will replace ClearCoverageTM, will result in changes that apply to preauthorizations related to our Essential Plan members.

Effective March 30, 2020, all inpatient and outpatient services will be subject to medical necessity review at the time of submission.

Additionally, be aware that when the CareAdvance Provider tool is activated, the Health Plan will continue to accept admission requests for Essential Plan members as a notification; however, the status of your notification will show as “pending” when submitted. We will process the notification by applying an initial administrative approval. Once we have applied the administrative approval, your request will show on your dashboard as “fully approved”.

Important Note: Submitting notice of an inpatient admission or outpatient services is not a coverage guarantee. We may review retrospectively to confirm the member’s contractual benefits for the care provided, as well as medical necessity and appropriateness of care. 

Please share this important information with all preauthorization staff. If you have questions, please contact your Provider Relations representative. 

 
 
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