 |
 |
We ask that you, as a provider participating in the PHCS Network, follow
the protocols of our customers' Utilization Management programs. These programs often
vary by health plan and by each patient's benefits with those health plans. We recommend
you call the phone number listed on the back of your patient's ID card to obtain
additional information regarding a specific health plan's Utilization Management program.
The following are guidelines that we recommend to help you efficiently facilitate the
Utilization Management process. Always:
- Complete the pre-certification process;
- Obtain authorization when required;
- Provide clinical information within the requested time;
- Exhaust entire appeals process; and
- Keep your patient informed at each stage of the Utilization Management and appeals process.
Appeals Process
As part of the Utilization Management process, you and your patient have the right to
appeal any decision that has been made. This should be accomplished by following the
appeals process guidelines. Just as Utilization Management programs vary by health plan,
so do appeals processes and guidelines. These variations also allow for compliance with
any applicable state or federally mandated laws.
For detailed information on specific patient's appeals processes, call the telephone
number on the back of your patient's ID card.
If PHCS is providing Utilization Management for the health plan, please contact us at
(800) 950-7040.
|
