Terminology
Please note that we use the term “prior authorization” for all of the items referenced below:
- Pre-certification (inpatient)
- Pre-authorization
- Prior approval
- Pre-determination
Important Notice for ARBenefits:
The Arkansas State and Public School Employees groups utilize Health Advantage coverage policies which can be found on healthadvantage-hmo.com.
Once there, click on the section titled view your ARKANSAS STATE OR PUBLIC SCHOOL PLANS here. Some services may require pre-certification/pre-authorization or be limited. For this group, you may view
the Summary Plan Description at arbenefits.org for a full list of covered services and exclusions
as well as pre-certification requirements.
Prior Authorization Information
Disclaimer
INPATIENT
Prior Authorization
A prior authorization for inpatient medical services is required. (note: the prior authorization requirement is waived for a hospital admission following a medical emergency. When possible, the covered person or the
treating provider is encouraged to send a notification of an inpatient admission related to treatment of a medical emergency within 48 hours.)
The following list of prior authorizations required for acute hospital care (admission, continued stay, discharge), post-acute inpatient facility care (admission, continued stay and discharge from an SNF, LTACH or Rehab),
and inpatient/outpatient standard medical procedures and surgeries. Some events require prior authorization, and others require notification only.
Acute hospital care
Admission: Notify us regarding all emergent admissions. Include medical records that support the need for an inpatient stay. Notification is required at the time of admission or within 24 hours of
admission (or 1 business day if admission occurs on a weekend) with sufficient clinical information and/or medical record documentation stating the purpose of the admission. You can provide notification of
admission via Availity or by using the form on our website.
Continued stay: When a member’s inpatient stay needs to be extended longer than planned or approved. Include medical records that support the need for continued stay. HA uses
InterQual criteria for review of Inpatient stays, if the inpatient level of care is not
met, the proposed service will divert to observation level of care.
Discharge from hospital: Notify HA when a member is discharged from the acute level of care. Include the discharge summary with the date and location (e.g., Home or SNF) of discharge. Discharge
information is vital for referral to Case Management which is used to provide members with assistance to available resources to reduce readmission risks.
Post-acute Inpatient facility (SNF, LTACH and Rehab)
Admission: Post-acute care includes acute rehabilitation, long term acute care and skilled nursing facility care. All post-acute admissions require a PA for level of care, per provider contract. Submit
the notification along with medical records that support the need for the requested level of care.
Continued stay: Submit the PA request with medical records that support the need for additional days at the requested level of care.
Discharge from a post-acute facility: Notify HA when a member is discharged. Include the discharge summary with the date and location (e.g., Home or SNF) of discharge. Discharge information is vital
for referral to Case Management which is used to provide members with assistance to available resources to reduce readmission risks.
ELECTIVE PROCEDURES
Standard Medical/Procedures/Surgical (Inpatient or Outpatient)
Elective procedures require prior authorization. Outpatient procedures require prior authorization.
High Tech Radiology (HTR) (Carelon)
Prior authorizations for a high-tech radiology are not required. Any other reviews are handled by a partner, Carelon. For more information, visit https://www.providerportal.com or call 1-866-688-1449.
Medical Oncology medications require prior authorization approval through Carelon Medical Oncology.
Behavioral Health (LUCET)
Prior authorizations are not required for behavioral health services. However, notification is required for inpatient behavioral health services (requirements are the same as Inpatient and Inpatient/Outpatient elective services noted above).
Any reviews for Behavioral Health are handled by a partner, Lucet. For more information, call 877-891-9177.
Pharmacy Resources
Retail: https://www.healthadvantage-hmo.com/providers/medical-providers/retail-pharmacy
Medical: https://www.healthadvantage-hmo.com/providers/medical-providers/medical-pharmacy
Organizational Determination Benefit Inquiry (ODBI)
Although prior authorizations are not required, providers may submit a request for an Organizational Determination Benefit Inquiry for a service not yet provided to help members and providers make decisions about care options. For more information about ODBI and to access the form, visit
https://www.healthadvantage-hmo.com/docs/librariesprovider9/providers/abcbs-authorization-org-det-request.pdf?sfvrsn=6d8c58fd_32
Post Service Reviews
For more information about post service utilization management reviews, visit https://www.healthadvantage-hmo.com/providers/resource-center/prior-authorization-for-requested-services
Forms
To access all provider forms, visit https://www.healthadvantage-hmo.com/providers/resource-center/provider-forms