Changes in Utilization Management during COVID-19 Emergency

Health Alliance and Health Alliance Northwest medical management has extended the discontinuation of clinical concurrent review for all inpatients through May 31, 2020, in consideration of the COVID-19 national medical emergency and the redeployment of healthcare workers. We understand the stress that the pandemic 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 continue the lifting of all Out-of-Network (OON) rendering site restrictions for Outpatient Preauthorization as it applies to Medicare members that became 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.

Temporary Preauthorization Auto-Approval of PAP Devices and Supplies for Medicare Members

Health Alliance and Health Alliance Northwest are temporarily granting auto-approval of certain PAP devices and supplies for our Medicare Advantage members. Providers will still be required to submit these requests into eviCore, but as of 5/20/20 the requests will be auto-approved for these members. Removing this barrier during the COVID-19 public health emergency is appropriate to increase access for members and decrease burden for providers.

The temporary auto-approval will include, but not be limited to:

NCD 240.2 Home Oxygen
NCD 240.4 Continuous Positive Airway Pressure for Obstructive Sleep Apnea
LCD L33800 Respiratory Assist Devices (ventilators for home use)
NCD 240.5 Intrapulmonary Percussive Ventilator
LCD L33797 Oxygen and Oxygen Equipment (for home use)
NCD 190.11 Home Prothrombin Time/International Normalized Ratio (PT/INR) Monitoring for Anticoagulation Management
NCD 280.14 Infusion Pumps
LCD L33794 External Infusion Pumps

Please see the Federal Register dated 4/6/2020 for guidance regarding PAP services during the COVID-19 pandemic. Information can be found here, in section U.2. For more information on our response to COVID-19, visit HealthAlliance.org/Coronavirus.

Be Sure to Provide Accurate Patient Information on Claims

Please be reminded that Health Alliance requires both the correct date of birth and member number for the patient, in order for claims to be processed. You may see an increase in claims disallowed due to the member number and date of birth not matching our enrollment records. To ensure the most accurate, rapid claims processing, please be sure all patient information you provide is accurate.

Find out more about electronic claim filing in the “Claims” section of the appropriate provider manual here. If you have questions, please contact your Provider Relations Specialist.

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