FLASH: Changes in Utilization Management during COVID-19 Emergency

In consideration of the recent surge of COVID-19 and the stress that this crisis places on the system, we understand the need to change some of our traditional monitoring processes.

Beginning August 27, 2021, Health Alliance, Health Alliance Northwest, and FirstCarolinaCare will offer the following through December 31, 2021.

• Waiving of clinical concurrent review for all acute inpatient hospitalizations, regardless of diagnosis.

We will continue to require notification 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.

• Approvals for oxygen at home are extended for Medicare Advantage and Commercial members with a COVID-19 diagnosis. The CMS flexibility will allow practitioners the option of treating their patients with home-use of oxygen during this time.
• In addition, for new prior authorizations (PA)* we are extending the usual 90-day authorization date span for elective surgeries, diagnostic testing, and referrals for office visits to 180 days. Once a PA approval has been granted it will be good for 180 days. We are then expecting the surgeon to reassess the patient before surgery.

*For services delegated to eviCore, the extension of prior authorization to 180 days will be effective September 7, 2021.

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.

Chester Ho, MD – SVP & Chief Medical Officer   

April Vogelsang, RN, MS – SVP & Chief Clinical Integration Officer 

Art Edgerton, MD – Medical Director, FCC

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