Authorization Policies and Procedures
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Section 2: Quality Management
Section 3: Utilization Management
Section 5: Special Member Status
Section 2: Quality Management
Standards of Care
HS-2.42 Quality Issue Corrective Action
HS-2.43
Provider Corrective Actions
HS-2.61 Standards of Care
HS-2.62 Adult Preventive Care
HS-2.63 Network Clinical Standards for Breastfeeding
HS-2.64 Childhood Preventive Care
HS-2.65 Physical Therapy Guidelines
HS-2.66 Staying Healthy Assessment Tool Administration
HS-2.67 Medical Necessity
HS-2.68 Continuity of Care
Section 3: Utilization Management
Annual Review and Reporting
HS-3.11 Utilization Management Program
HS-3.13 Inpatient Review
HS-3.16 Appeals of UM decisions
HS-3.18 Disclosure of UM Process to Providers and Members
Treatment Authorization Requests (TAR) Review
HS-3.21 TAR Process
HS-3.21.1 TAR Timeliness
HS-3.22 TAR Processing
HS-3.22.1 Hospital Stay Less than 24 Hours
HS-3.23 Long-Term Care TAR Processing
HS-3.24 Criteria for Two Year Extension of Long-Term TAR
HS-3.25 Treatment Authorization
Request (TARs) – Response Times
HS-3.26 Treatment Authorization
Request – Deferral
HS-3.27.1 TAR procedure for transplants
HS-3.28.1 TAR Review Process for MRI
HS-3.28.2 Bariatric Surgery
HS-3.28.6 Nebulizers
HS-3.29 Skilled Nursing Authorizations and Denials
HS-3.29.1 Home Health Care
HS-3.30 Authorization Time Period
Referral Authorization
HS-3.32 RAF Process
HS-3.36 Second Medical Opinion
Case Management
HS-3.42 Missed Appointments and Patient Recall
HS-3.44 Accessibility
HS-3.48 Sterilization Consent Protocol
HS-3.49 Member Access to Obstetrical and Gynecological Services
HS-3.410 120-Day Health Assessments
HS-3.411 Confidentiality
HS-3.412 Hospital transportation from PCP office
HS-3.413 Administrative Day Status
HS-3.414 Early Intervention Services
HS-3.415 Developmental Disabilities Services
HS-3.416 Non-Emergency Medical Transportation Coordination
HS-3.417 Provisions for Interpreting Services
Provider-Related Issues
HS-3.52 In-Office Telephone Triage
HS-3.53 Medical Records
HS-3.56 Nurse Midwife Guidelines
HS-3.57 Physicians Assistants
HS-3.58 Nurse Practitioner Guidelines
HS-3.59 Medical Assistants
HS-3.510 Allied Health Provider Services
HS-3.511 Restrictions on Infant Formula Marketing
HS-3.512 Infection Control Practices
HS-3.513 Provider Deleting a Member from Case Management
HS-3.514 Claims appeal override
HS-3.515 Facility Site Reviews
Durable Medical Equipment (DME) and Medical Supplies
HS-3.61 DME Authorization
HS-3.62 DME Authorization Process
HS-3.63 Medical Supplies Authorization
HS-3.64 Emergency Wheelchair Repairs
HS-3.65 Provision of Breastfeeding-Related DME
HS-3.66 Provision of Human Milk Bank Services
HS-3.67 Restrictions on Durable Medical Equipment (DME)
HS-3.69 Wound Vac
HS-3.27 Treatment Authorization Request (TAR) review process for TENS Unit
HS-3.28 TAR Review Process for BiPAP and CPAP Units
HS-3.28.3 TAR Review Process for Seat Lift
HS-3.28.4 TAR Review Process for the Vest
HS-3.28.5 TAR Review Process for Bone Stimulator and Ultrasound Device
Provision of Services
HS-3.71 Provision of Medically-Necessary Lactation Specialist Services
HS-3.72 Provision of Family Planning Services to Members
HS-3.73 Post Partum Hospital Stays
HS-3.74 Dental Anesthesia
HS-3.75 Dental Work for Alliance Members
HS-3.76 Physical Therapy Requests for Additional Time per Visit
HS-3.77 Authorization of MRI Studies Ordered by Primary Care Physicians
HS-3.78 Biofeedback for Incontinence
HS-3.79 Experimental Treatment and Therapies
HS-3.80 External Independent Review
HS-3.90 DME and medical supplies under $100.00
HS-3.91 OOA Referrals
Section 4: Pharmacy
HS-4.1
Pharmacy Operations Management
HS-4.2 Pharmacy TAR Processing
HS-4.3
Pharmacy & Therapeutic Committee Function
HS-4.4 Enbrel (Etanercept)
HS-4.5 Tramadol (Ultram)
HS-4.6 Cox-2 Inhibitors
HS-4.7 Leflunomide (Arava)
HS-4.8 Non-FDA approved drugs and herbal remedies
HS-4.9 Leukotriene Modifiers
HS-4.11 Fluoxetine (Prozac)
HS-4.13 Therapeutic Equivalence of Generic Drugs
HS-4.14 Aricept (Donepezil)
HS-4.15 New Member, Continuing Care
HS-4.17 Antihistamines, non-sedating
HS-4.18 Anti-Obesity Drugs
HS-4.20 Anti-hypertensive, New Drug (NF)
HS-4.21 Patches, Transdermal
HS-4.22 Migraine, NF Drugs
HS-4.23 Synagis (Palivizumab)
HS-4.24 Hydrocodone/APAP, NF
HS-4.25 Hepatitis C Treatment Guidelines
HS-4.26 Criteria for approval of sildenafil (and subsequent agents for erectile dysfunction)
HS-4.27 Drug Recall
HS-4.29 Somatropin (Serostim) Guideline
HS-4.30 Pharmaceutical Services Access
HS-4.31 Actiq
HS-4.32 Other Non-formulary drugs
HS-4.33 Long-Acting Narcotics
HS-4.34 Technology Assessment
HS-4.35 Human Growth Hormone
Section 5: Special Member Status
HS-5.1 Administrative Member Identification
HS-5.5 Accessibility to Specialty Care
Section 6: Health Education and Disease Management
Administrative
HS-6.11 Health Education and Promotion Program
Topic-Specific Education
HS-6.21 Smoking Cessation
HS-6.22 Diabetes Education Program
HS-6.23 Family Planning
HS-6.24 Well Child Care
HS-6.25 Stress Management
HS-6.26 Hypertension Management
HS-6.27 Prenatal Health
HS-6.28 Therapeutic Abortion Counseling
HS-6.29 Weight Reduction
HS-6.210 Substance Abuse Intervention
HS-6.211 Parenting
HS-6.212 Family Counseling
HS-6.213 Breast Self-Examination
HS-6.214 Breastfeeding Promotion, Education and Counseling
HS-6.215 Perinatal Transportation Assistance for Medi-Cal Members
HS-6.216 Medical Nutrition Therapy
HS-6.217 Asthma Education Program
Chronic Disease Management
HS-6.31
Physical Therapy for Chronic Back Pain & Other Longstanding Static
Conditions
HS-6.33 Diabetic Management