Utilization Management Turnaround Times

Utilization Management Turnaround Times

A decision to pre-approve, modify or deny a specialty or service referral request must be made within certain timeframes. These are based on the urgency of your medical condition and treatment needs, but most decisions are made within five business days of receiving necessary information to make the decision. If fast handling of your case is needed due to urgent medical needs, your doctor may ask for an "expedited" review. These will be completed by the plan as soon as possible based on your situation, but no later than 72 hours of receipt of the request and pertinent information to make a decision. Some services are considered an urgent concurrent review, meaning they are reviewed as you are receiving on-going services. An example of this is when you are in the hospital. Services are reviewed within 24 hours of the hospital's request for approval.

Notification of Decision

Your doctor(s) and medical group will receive a phone call, fax or electronic notice of the decision within 24 hours of the decision. This is followed by written notice mailed to you, your PCP and the specialist within two days. If denied, the notice includes an explanation of the reasons for the denial or modification and information on how to file an appeal with WHA Member Services or in writing, directly with our Appeals and Grievances Department. It also includes information on how to contact the Office of Personnel Management. See below for Appeals & Grievances Process.

Criteria Used

Criteria primarily used by WHA’s physician reviewers to make medical necessity decisions at the health plan level include the following sources:

• MCG® (formerly Milliman Care Guidelines) – Acute, Ambulatory & Chronic Care guidelines 
• UpToDate® – Evidence-based physician authored clinical decision support resource
• Hayes New Technology Assessment guidelines – Experimental guidelines
• InformedDNA Genetics, Decoded – Geonomics industry
• World Professional Association for Transgender (WPATH), Standards of Care (SOC), Version 8
• The American Psychiatric Association and Endocrine Society

You may obtain a copy of the actual benefit provision, guideline, protocol or other similar criterion on which the decision was based, upon request and free of charge.