Prior #Authorization

• Preauthorization is A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment (DME) is medically necessary.  Sometimes called prior authorization, prior approval or  precertification.
• Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost. ^{Health Net Glossary}  * See also YOUR EOC, Evidence of Coverage!
• IMHO Insurance Companies are not doctors and a lot of people and regulators agree, thus the pending laws and investigations.
  • Exhausted by prior authorization, many patients abandon care: AMA survey
    • hawaii news now.com/ doctors-say-insurance-approval-reform-would-help-patients-get-care-faster/
    • kff health news.org/prior-authorization-outrage
  • Prior Authorization in Medicare Advantage Plans: How Often Is It Used?  KFF 10/2018
  • Prior Authorization - Regulatory Investigation aka “preauthorization” and “precertification” KFF.org 5.20.2022
  • California Senate Bill 250  * Senator Pan   would require that insurers consult with doctors on which services require authorizations, streamline the process, less paperwork and allow patients to get the care they need faster.
    • SB 250 would require health plans to exempt physicians from prior authorization rules if they have practiced within the plan's criteria 80% of the time. ^CMA.Docs.org
  • PRIOR AUTHORIZATION REQUIREMENTS HALTED FOR CERTAIN SERVICES 
  • Parody If Health Care was honest  VIDEO
  • UnitedHealth launches ‘gold card' to ease prior authorization burden
  • Use of Prior Authorization Up in Medicare Advantage Plans, Senate Report Finds
  • ajmc.com/prior-authorizations-and-the-adverse-impact-on-continuity-of-care
• See our main webpage on Medical Necessity

Resources, Links & Bibliography

• cal matters.org/new-bill-pushes-insurers-to-stop-playing-doctor
• Payer Denial Tactics — How to Confront a $20 Billion Problem
• cal matters.org/richard-pan
• cma docs.org/prior-authorization-bill
• Plaintiff whose insurer delayed surgery is awarded $14 million over opioid dependency
• SCAN Pharmacy Prior Authorization Forms  SCAN Website
  • General Prior Authorization  SCAN Website
• Her spine surgery was denied. Doctors say it's all too common.
  Insurance denied 18-year-old Nala White’s surgery for degenerative disc disease. After NBC News reached out, it was approved the next day.    NBC News.com  

Independent Medical #Review (IMR) Program

VIDEO's

DMHC Help Center & Independent Medical Review VIDEO

An Independent Medical Review (IMR) is where expert independent medical professionals review specific medical decisions made by the insurance company. The California Department of Insurance (CDI) administers an Independent Medical Review program that enables you, the insured, to request an impartial appraisal of medical decisions within certain guidelines as specified by the law.

Health insurer delayed her MRI. Meanwhile, the cancer that would kill her was growing.

An IMR can be requested only if the insurance company’s decision involves:

• The medical necessity of a treatment,
• An experimental or investigational therapy for certain medical conditions, or
• A claims denial for emergency or urgent medical services.

It is important to note that the IMR process cannot be used for an insurance company decision that is based on a coverage issue. Only decisions regarding a disputed health care service, as it relates to the practice of medicine, that do not involve a coverage issue are qualified for the IMR program.

You are required to exhaust the internal appeals/grievance process of your particular insurance company before applying for an IMR with the CDI.  Click here to read full article on Department of Insurance Website

• IMR on CA Department of Insurance Website
• What Is an Independent Medical Review?
• Who Can Request an Independent Medical Review?
• When Can an Independent Medical Review Be Requested?
• What Issues Are Eligible for an Independent Medical Review?
• What Issues Are Not Eligible for an Independent Medical Review?
• How Does the Independent Medical Review Program Work?
• What Are the Criteria Used in an Independent Medical Review Determination?
• Is There a Way to Process an Independent Medical Review More Quickly in Extraordinary Circumstances?
• Will an Independent Medical Review be Costly?
• Does Independent Medical Review Participation Prevent Future Legal Action?
• Are Medical Records Kept Confidential in the Independent Medical Review Process?
• How Do I Request an Independent Medical Review from the California Department of Insurance?
• Health Insurance Terms and Phrases
• The California Department of Managed Health Care (DMHC)  The DMHC regulates HMOs and some PPOs in California  – Try using the Insurance Company procedure first
• Complaint Form &  IMR
• 1-888-HMO-2219
• [email protected]
  • Contact Form
• CA Department of Insurance  
• IMR – Independent Medical Review  
• ONLINE complaint form insurance.ca.gov/complain 

• Magellan Mental Health
  • Policy Statement
  • Magellan* provides procedures for the expeditious processing of requests for external appeal of adverse determinations through an Independent Review Organization as required by applicable law or customer contract.
  • Purpose
  • To establish standards to assure independent and timely review of disputed health care services to assure that appropriate, beneficial treatment interventions are made available to members. ^{Magellan Mental Health}

• Disability Rights.org 5 page pdf 

• National Health Law Program  12 page pdf on Internal Grievances & External Review in Service Denials in Covered CA Plans
•  
• Sections 10169 through 10169.5 of the California Insurance Code (CIC), which became effective January 1, 2001, explain the IMR process in detail. In addition, Section 10145.3 explains the IMR process as it relates to experimental or investigational therapies.

Our Web Pages on

• Medical Necessity – reasonable and necessary Independent Medical Review
• Appeal & Grievances? Medicare – Medi Cal – Covered CA