AUTHORIZATIONS

Referral Authorizations

 AMM can receive referral authorizations requests directly from participating Primary Care Physicians on-line. PCPs can complete the website form with the convenience of pull down enrollment lists, CPT codes, ICD-9 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 Cerecons 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 in place that consistently generates 24 to 48- hour turnaround for routine requests and stat or urgent turnaround in two to four 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. Weekly reports are mailed to health plans as required individually. Weekly Utilization logs are generated for the IPA Utilization Committee as well as denial logs, and any custom programmed reports. As mentioned above, PCP’s, Specialty Providers, IPA Officers and the Medical Director have real time access to Cerecons 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 Local Coverage Determinations (LCD)
      •  Medicare National Coverage Determination (NCD)
      •  Local Coverage Medical Policy Article
      •  Medicare Benefit Policy Manual
  •  Health Plan Criteria (e.g. Coverage Summary, Medical Policy)
  •  Interqual Cloud Care Guidelines 2019
  •  MCG 23rd Edition
  •  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 23rd Edition
      • Interqual Cloud Care Guidelines
      • 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.