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Prior-Authorizations

Click here to access the Prior Authorizations form >

Our Department of Utilization Management 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.

Prior authorization is required for certain services. The Prior Authorization List details which covered services require authorization.

Click here to access the Prior Authorization List >

NextLevel Health Prior Authorization Process

  1. You can submit a Prior Authorization (PA) by fax or phone. The form can also be downloaded Click Here
  2. The PA nurse reviews your request form according to the clinical guidelines and InterQual medical necessity criteria.
  3. 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.
  4. 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.
  5. The Medical Director makes a decision and includes the results in the review.
  6. The PA nurse notifies you and the Member of the decision as policy requires.
  7. 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:

Decisions for all urgent prior authorization requests will be made within three (3) business days. Non­-urgent requests will be made within 14 calendar days from receipt of request.