Purpose

IMCare requires notification and/or prior authorization for some procedures, tests, pharmaceuticals, and services within and out of its network. The Service Authorization requirement is used to safeguard against inappropriate and unnecessary use of health care services. Some authorization requirements are governed by State law and Federal regulations.

Requests for authorization after the service has been provided are subject to the same review criteria as those that are received prior to providing the service.

For more information, please refer to the IMCare Provider Manual, Chapter 5 - Service Authorization.

Process

Receiving an approval for a Service Authorization request does not guarantee payment. Providers must follow IMCare billing policy guidelines, and the IMCare member must be eligible at the time the service is rendered.

Appropriate documentation for medical necessity is required for all requests.

When members have private insurance, providers must follow authorization and other rules that apply to the primary insurance. Providers should obtain Service Authorization, when required, prior to providing a service.

There is an exception when Medicare Fee-for-Service (FFS) is primary: for members with Medicare FFS as primary, if Medicare pays for any service, no authorization is needed for IMCare to pay the copay or coinsurance. If Medicare denies or does not cover, all authorization rules apply.

Review

All IMCare Utilization Management (UM) determinations are based only on the appropriateness of care and service and coverage. IMCare does not reward practitioners or other individuals for issuing denials of coverage or care. There are no financial or other incentives for IMCare UM decision makers to encourage decisions that result in underutilization.

Timeline

IMCare has 10 days to respond to non-urgent pre-service (pre-authorization) requests and 30 days to respond to retroactive, (post-service) requests.

An urgent pre-service request is a request for authorization in which the provider requests an immediate determination or IMCare determines that non-urgent time frame would jeopardize the member's life or health. IMCare will make the determination and notify the member and provider within 72 hours of receipt of request.

Non-formulary medication requests will be completed within 72 hours of receipt of the request unless it is an expedited request. Expedited non-formulary medication requests will be completed within 24 hours.