Prior-Authorizations

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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. NextLevel Health uses InterQual®  criteria to determine medical necessity. 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.

For a list of DASA and Behavioral Health Services that do not require authorization please click on this link: DASA BH PreAuth Notice

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:

Prior Authorization Request Fax Numbers
844-776-1664 – Inpatient/Outpatient Prior Auth.844-895-2705 – Inpatient Concurrent Review
844-318-9183 – Behavioral Health844-303-2643 – Medical Records
833-231-2304 – LTSS Service Plan Requests800-424-4833 – Imaging / Radiology
844-776-1664 -BioPharmacy Coverage Determination

NextLevel Health Prior Authorization Process:

1
The PA nurse reviews your request form according to the clinical guidelines and InterQual medical necessity criteria.
2
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.
3
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. NextLevel Health uses InterQual® criteria to determine medical necessity.
4
The Medical Director makes a decision and includes the results in the review.
5
The PA nurse notifies you and the Member of the decision as policy requires.
6
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.