Precertification Timeliness Standards

HMSA's Medical Management department reviews precertification requests and provides the physician with a determination of benefit coverage within the timeliness standards established by federal legislation and the National Committee for Quality Assurance (NCQA).

For urgent precertification requests (called "expedited" for HMSA Akamai Advantage® members), a decision will be made and communicated within 72 hours from the receipt of the request or 48 hours after the earlier of a) our receipt of additional necessary information or b) the deadline we specify for the additional necessary information to be provided. A precertification is considered urgent when:

• Processing the request in a routine manner could seriously jeopardize the life or health of the member or the member's ability to regain maximum function, based on a prudent layperson's judgment or
• In the opinion of a practitioner with knowledge of the member's medical condition, a delay would subject the member to severe pain that cannot be managed without the care that is the subject of the request.

The fact that a scheduled service is imminent does not define a precertification request as urgent.

Routine precertification requests are determined and communicated to the physician on average within five to seven calendar days of receipt of all necessary information. However, for PPO/HMO members, please note that 15 calendar days are allowed by the U.S. Department of Labor regulations implemented in July 2002, with some provisions for extensions of time, and some cases may take that long. For HMSA Akamai Advantage members, 14 calendar days are allowed by CMS regulations.

Required Information for Precertification Request

Precertification requests must include the applicable information listed below:

• Patient information: Name, address, date of birth, sex, HMSA member ID number, and information about any other insurance coverage available. Also, please include the subscriber's name if the patient is not the subscriber.
• Attending physician or provider information: Name, address, telephone number, fax number, and HMSA provider number.
• Referral: If precertification is being requested for an HMO member and services require a referral, one must be sent either prior to or concurrent with the precertification request. The precertification request cannot be processed without the necessary referral.
• Applicable clinical information about the proposed service or equipment:
  • History of present illness; primary and secondary diagnoses (both ICD-9/ICD-10 code and description); proposed procedure, treatment, or service (including applicable CPT and HCPCS codes); and the frequency of services or expected duration of treatment.
  • For durable medical equipment as applicable, please include information about the make and model number of the equipment, cost itemization, and the estimated length of time the item will be needed.
  • If services are to be performed at a higher-level setting than usual (e.g., surgery will be performed on an inpatient basis when it is normally performed in an ambulatory surgical center (ASC)), please include the date of the proposed admission, date of the procedure, the reason the procedure is being performed at the higher-level setting, history of present illness, and the expected length of the stay.
  • Some services (e.g., physical and occupational therapy) require a treatment plan that includes goals; prognosis; the number of days, services, or procedures requested; and the frequency and expected duration of the services. If you are asking that the number of previously approved services be extended, please provide an updated treatment plan and clinical information supporting the need for an extension, including range of motion, manual muscle test and functional capacity (for PT requests) or any changes in the patient's diagnosis or prognosis.
  • If you are asking HMSA to evaluate a new treatment or procedure for possible benefit coverage, please include clinical information supporting the appropriateness of the service, any available literature, and current specialty assessment reports.
  • If the physician is requesting outpatient services (e.g., IV therapy) following an inpatient stay, they must include a copy of the discharge summary.
• Facility information: Name, address, telephone number, fax number, and HMSA provider number. Also include information about the type of facility (e.g., inpatient, outpatient, skilled nursing facility (SNF)).
• Contact: Please include the name and telephone number of a contact person familiar with the patient's case to provide additional clinical information if needed.

Physician Reviewer

Determinations of whether HMSA criteria for benefit payment are met by qualified medical professionals. Board-certified specialists are available for consultation and participate in reviews of precertification requests as needed. Precertification denial decisions are not made at the staff level. Denials can be made only by medical directors, all of whom are physicians.

HMSA physician reviewers are available to discuss precertification decisions with treating physicians, who may contact the reviewers via the Precertification Unit (HMSA Directory - Provider Resources).

HMSA does not provide incentives to practitioners or individuals involved in the Medical Management department's decisions to deny or withhold care. The department's decision-making is based only on appropriateness of level of care and service and existence of coverage.

Revision History