Prior-Authorizations – Next Level Health

Our Utilization Management team is responsible for receiving, processing and responding to your prior authorization requests. These decisions are based on care and service relevance and benefit coverage existence. Procedures are followed based on a Member’s medical necessity. This reduces administrative barriers for doctors and other providers. All inpatient and outpatient requests and notifications must include your NPI number for proper processing of your claim.

Online

USE OUR ONLINE PRE-AUTH TOOL!

PRE-AUTH TOOL

SUBMIT A PRE-AUTH REQUEST!

PROVIDER LOGIN

Via Fax

Select the links to download the following forms to submit via fax:

Out Patient Prior Authorization Request
In Patient Prior Authorization Request
Behavioral Health Prior Authorization Request
BioPharmacy Coverage Determination Request
Medical Records – Fax Submissions at 844.303.2643

Prior Authorization Request Fax Numbers
844-776-1664 – Inpatient/Outpatient Prior Auth.	844-895-2705 – Inpatient Concurrent Review
844-318-9183 – Behavioral Health	844-303-2643 – Medical Records
833-231-2304 – LTSS Service Plan Requests	800-424-4833 – Imaging / Radiology
844-776-1664 -BioPharmacy Coverage Determination

NextLevel Health Prior Authorization Process:

The PA nurse reviews your request form according to the clinical guidelines and InterQual medical necessity criteria.

If medical necessity is met, the PA nurse enters an approved quantity and decision code. He or she completes the authorization request and sends the form back to you.

When medical necessity is questioned, or when necessary clinical information has been requested but not received, the case is referred to the appropriate Medical Director. He or she reviews the case and makes a decision.

The Medical Director makes a decision and includes the results in the review.

The PA nurse notifies you and the Member of the decision as policy requires.

You are notified about the best way to contact a Medical Director (or appropriate practitioner reviewer) to discuss any Utilization Management (UM) denial decisions.

Please Note:

Effective on January 1, 2018, decisions for all urgent prior authorization requests will be made within 48 hours or two (2) calendar days. Non-urgent requests will be made within 4 calendar days from receipt of request.