AUTHORIZATIONS

Referral Authorizations

 AMM can receive referral authorizations requests directly from participating Primary Care Physicians on-line. PCPs can complete the EZNET website form with the convenience of pull down enrollment lists, CPT codes, ICD-10 codes, and contracted specialist’s lists. The submitted referral request has a permanent tracking number assigned instantly and the request automatically updates the EZ-CAP database at AMM. If auto approval rules are determined by the IPA Medical Director and UM Committee, then AMM can program EZ-CAP to automatically approve authorizations submitted online that meet those specific criteria. IPA providers must comply with certain minimum computer hardware and software specifications and generate sufficient referral request volume.

 AMM has a referral authorization process that consistently delivers a turnaround time of 5 business days for Commercial and Medi-Cal, and 14 calendar days for Medicare for routine requests. For stat or urgent requests, the turnaround time is between 24 to 72 hours. This process requires PCP offices to log into a secure website to enter their referral requests. Stat, urgent, auto approved authorizations and other fast track protocols can be programmed into the process for expedited turnaround.

 Each day's totals are statistically reconciled to the member letters so that all requests are accounted for. Deferred requests are tracked and letters notifying members of each approved and denied request are mailed to members daily. Reports are delivered to health plans on a weekly, bi-weekly, or monthly basis as individually required. Scheduled utilization logs, denial logs, and any custom-programmed reports are generated on a regular basis for the IPA Utilization Committee. As mentioned above, PCP’s, Specialty Providers, IPA Officers and the Medical Director have real time access to EZNET or EZCAP authorization data.

 The organization provides services, free of charge, in the requested language through bilingual staff or an interpreter.  

 Standardized criteria for outpatient services requiring pre-authorization and for inpatient services for Medicare members will include the following, but not limited to:

  •  Plan Eligibility and Benefit Coverage
  •  CMS Criteria
      •  Medicare National Coverage Determination (NCD)
      •  Medicare Local Coverage Determinations (LCD)
      •  Local Coverage Medical Policy Article
      •  Medicare Benefit Policy Manual
  •  Health Plan Criteria (e.g. Coverage Summary, Medical Policy)
  •  MCG 28th Edition, along with the criteria listed above.
  •  InterQual Guidelines 2023
  •  Other Evidence-based resources
  •  Up to Date online portal for additional physician reviewer education
  •  Behavioral Health Guidelines

 Standardized criteria for Commercial / Medi-Cal Members will include the following, but not limited to:

  • Plan Eligibility and Benefit Coverage
  • Federal state
  • State Coverage
  • Health Plan Specific Criteria
  • MCG 28th Edition
  •  InterQual Guideline 2023
  •  Other Evidence-based resources 
    • Up to Date online portal for additional physician reviewer education

    A copy of the criteria used to make a determination is available upon request.