Prior authorization processes can understandably be complex and difficult to follow. At WHA, we are focused on working with you to simplify the process and provide a thorough and timely response. Below is some basic feedback on submitting your request as well as timelines and contact details.
If you or your office receive a denial for a medical service, procedure, or prescription drug prior authorization (PA) request, carefully review the denial letter to understand the reason for the denial and any specific documentation that may be required for reconsideration. If you determine that you would like to proceed with appealing the denial, your next steps may be to discuss the denial with the member. You may determine that additional supporting documentation or clinical evidence may need to be gathered to add to your appeal.
Once you receive a denial, please submit all requests, submissions, or intent to appeal to:
Mail: Western Health Advantage
ATT: Appeals & Grievances Department
2349 Gateway Oaks Drive, Suite 100, Sacramento, CA 95833
Secure Fax: 916.563.2207
Secure Email: appeal.grievance@westernhealth.com
The medical groups and WHA clinical teams consider all medical documentation in their review. It is extremely helpful when documentation reflects more recent episodes of care. When WHA reviews these requests and appeals, documentation submitted on the prior authorization sheet is not considered to be clinical documentation. Therefore, please make sure your clinical notes are consistent with the submitted updates. This will save a lot of time spent on back-and-forth requests for these kinds of details. Our clinical teams will review and corroborate updates on the appeals request sheet alongside clinical notes for medication, clinical history, and treatment updates.
WHA’s Timelines for the Appeals Process
- Standard – Appeals are not deemed urgent or expedited and will be completed within 30 calendar days. A delay in a final decision may occur if additional information is needed for the reviewer to make an informed decision.
- Expedited – Appeals are completed within 72 hours upon receipt of the request because the treatment request may be addressing severe pain or an imminent and serious threat to the health of the member, including but not limited to potential loss of life, limb or major bodily function. A delay in a final decision may occur if additional information is needed for the reviewer to make an informed decision.
WHA strives hard to complete these requests per the timelines above. To adhere to these guidelines, we request that you review your submission from the clinical acuity perspective. If your appeal request does not meet the details on clinical acuity above, please submit your request as a standard or routine appeal. Expedited appeals sent without adequate support of acuity, often result in requests for more information. If this is not available, it may result in an upholding of the initial denial based on initial information submitted. This is particularly exacerbated and problematic for such cases submitted on a Friday as expedited. This is because we are not often able to get the additional documentation or conversations with the provider requesting the appeal on the weekend. Our clinical team of nurses and physician reviewers are committed to supporting your desire to provide patients with the right care at the right time and right place. In line with this commitment, our clinical leadership, inclusive of our Medical Director and Chief Medical Officer are available for clinical discussions and will often proactively reach out to you to discuss a case or scenario. This is the WHA difference – close partnership with our providers to achieve the best outcomes for our patients.
Review WHA Criteria
Last but not least, we request that you review our criteria for prior authorization. This is readily available to you via the provider portal or our website. These criteria reflect the prevailing clinical guidelines and the provisions of the evidence of coverage criteria. It is useful to know that these criteria and guidelines are subject to ongoing updates when the literature changes. They are then reviewed for approval with the leadership of your medical group representatives at our monthly meetings.
Status checks on your appeal request may be made by contacting WHA’s Member Services Department, at 916.563.2250, Monday through Friday, between the hours of 8 a.m. to 6 p.m. (excluding holidays).