Health care management decisions
Health care treatments, drugs and supplies that are not part of the member’s benefit plan or are not medically necessary are not covered. We determine if a treatment, drug or supply is medically necessary and, therefore, covered. Additionally, if health services can be provided in more than one medically appropriate setting, ConnectiCare may determine which setting is eligible for benefit coverage and the health services must be provided in that setting in order for the member to be eligible for benefit coverage. These benefit determinations are made through various health care management procedures, including pre-service review, concurrent review, inpatient hospital readmission review, post-service review, and a reconsideration process.
Note: ConnectiCare reserves the right to use third-party vendors to administer benefits, including utilization management services.
Pre-service review (before services are rendered)
- Pre-admission certification for elective hospitalization
- Preauthorization for medical necessity of selected elective surgical procedures inpatient and outpatient
- Preauthorization for elective care from out-of-network providers (excluding Point-of-Service plans)
- Preauthorization for non-acute facility admissions (sub-acute, skilled nursing facility, hospice, etc.), home health care, durable medical equipment (DME)
- Preauthorization for prescriptions and injectable medications
Note: Admission to a skilled nursing facility for rehabilitation, in the absence of a preceding hospitalization or acute episode of illness or injury, requires preauthorization and is subject to medical necessity review.
Concurrent review (while services are being rendered)
- Evaluation of discharge readiness based on utilizing nationally recognized criteria received during an inpatient admission
- Assessment of appropriateness of site for care; including the medical necessity of emergency/urgent admissions
- Facilitation of care delivery throughout the continuum of care
Inpatient hospital readmission review
- Review resulting from a member who is discharged from a hospital and is then readmitted to the same hospital or same hospital network within View our complete Hospital Readmission Policy
Post-service review (after services are rendered)
- Review of clinical information for medical necessity and appropriateness of service
Peer to peer process (upon an adverse medical determination)
- Review by the clinical peer reviewer who made the initial adverse determination, only upon request by the physician who originally requested approval of the services
Decision-making check financial incentives policy
When health care management decisions are made, they are based on the member’s benefit plan and the appropriateness of the proposed health care treatments, drugs and supplies for that member. We do not reward practitioners or other individuals conducting utilization review for issuing denials of coverage for health care treatments, drugs, and supplies. We offer no incentives to promote decision making that would result in inappropriate denials of services.
We will make non urgent pre-service determinations within 15 business days from receipt of the request. ConnectiCare will notify the member and the attending physician of the decision in writing. For questions about preauthorization of procedures, 1-800-562-6833.
When an adverse determination has been issued, providers have the right to the following:
Note: Utilization managers are also available for other Utilization Management questions from 8 a.m. to 5 p.m., Monday – Friday at 1-800-562-6833. After hours, please leave a voicemail message.