FLASH: Changes in Utilization Management during COVID-19 Emergency

For the next 30 days, Health Alliance and Health Alliance Northwest medical management will discontinue clinical concurrent review for all inpatients, in consideration of the national medical emergency and the redeployment of health care workers. We understand the stress that this potential crisis places on the system and the need to change some traditional monitoring processes.

Health Alliance and Health Alliance Northwest will continue to need to be notified within 24 hours of a hospital admission. We expect that all transfers will continue to be authorized and that we will be notified at the time of discharge. It’s critical that our members receive their benefits of post-acute care management from our care management team. We will do everything we can do to be timely and attend to skilled nursing facility discharges quickly. 

We will be lifting all Out-of-Network (OON) rendering site restrictions for Outpatient Preauthorization as it applies to Medicare members effective 3/23/2020. For any case that is initiated for the impacted membership while CMS’s Section 1135 Waiver is in effect, we will not restrict prior authorization based on OON/Non-Participating status of the rendering site and the case will proceed through medical necessity review.

Additional modifications previously communicated:

• Extended the usual 90-day prior authorization (PA) for elective surgeries to 180 days. Once a PA approval has occurred it will be good for 180 days. We are then expecting the surgeon to reassess the patient before surgery.
• Approval of all provider (physician and advanced practice provider) telehealth services.
  • Please see appropriate CPT codes for telehealth, which may be used for chronic disease management, acute care management, follow up, post-operative care, etc.
• Extended 90-day prescription refills.
• CT scans of the chest will be auto-approved when indicated for coronavirus.
• Per Medicare guidelines, we’re temporarily allowing additional SNF coverage for those who recently exhausted their SNF benefits without the start of a new benefit period.

We will continue to look at practical options to support the clinical needs during the emergency period of time. And we invite our provider network to visit our COVID-19 webpage for up-to-date information about the illness, our response and questions about coverage. Thank you for your care and concern for our members and the communities we serve. 

Robert G Good, DO, MACOI April Vogelsang, RN, MS

SVP & Chief Medical Officer  SVP & Chief Clinical Integration Officer

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