Affinity Health Plan

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  • Authorizations

    PRIOR AUTHORIZATION For Medical Services (Non-Pharmacy Services)

    REMINDER: A prior authorization request is a request for service approval by the member, or a provider on the member’s behalf, to evaluate medical necessity and eligibility for coverage, before such covered service is provided to the member. In order to determine the medical necessity of a service and reduce the time from when a request is made to when it is approved, the authorization request should be accompanied by all necessary clinical information to support the request for service. Once clinical information is received and reviewed and an approval is granted, an authorization number will be assigned for billing purposes. In order for the claim to be eligible for reimbursement, the service authorized must match the service on the claim and the claim’s received date must be after the authorization approval date.

    Prior authorization is required for services listed in this document.

    Affinity Health Plan (Affinity) encourages providers to supply clinical documentation upon request of an authorization to facilitate expedient responses and reduce delays in treatment.

    Note: Failure to comply with the requirements described above may result in claims being denied in whole or in part and, as required under your agreement with us, the member being held harmless.

    Retrospective Review

    Retrospective review is the process of determining coverage post service. Affinity’s retrospective review is limited to:

    • Unable to Know Situations
      • The member is not able to inform the provider about their insurance coverage, or the provider verified different insurance coverage prior to rendering services.
      • The member is unable to speak (e.g., incubated or in a coma) and cannot provide insurance information.
      In these cases, please notify us within 24 hours after insurance is verified and include clinical and supportive documentation describing the reason for the delay in the authorization request.
    • Unable to Verify Primary vs. Secondary Insurance Coverage In this case, we will honor authorizations from the primary carrier as long as the service is a covered benefit.
    • Not Enough Time Situations The member requires emergency medical services and pre-authorization cannot be completed prior to service delivery. In this case, Affinity will accept the authorization request as long as it is received as soon after the emergency has been handled, and the request is made prior to submitting the claim for payment.

    Along with the request for a retrospective review, all clinical documentation to support the review must be received with the request from the provider.

    Affinity’s automated line for providers offers information on the status of an authorization request. When calling 866.225.0506 a provider must have his or her authorization number ready to provide the automated system in order to verify if an authorization is approved or denied. This service allows for an expedited process and eliminates the need to call the Affinity Medical Management for authorization status.

    Effective summer 2017, providers are able to check the status of authorizations via the provider portal. Detailed instructions will follow closer to the effective date.

    Affinity Health Plan is continuing our expanded partnership with eviCore Healthcare. Since January 1, 2017, eviCore has managed the authorization process for radiation therapy, ultrasound, sleep management, physical therapy (PT), occupational therapy (OT), speech therapy (ST) and cardiac imaging and radiology services. For more information and codes related to these services, please visit https://www.evicore.com/healthplan/Affinity.

    Please note the following points of clarification on the authorization services provided via Affinity Health Plan’s recently expanded partnership with eviCore Healthcare:

    Ultrasound
    For a routine pregnancy, the first two ultrasounds – nuchal translucency (76813) and fetal anatomy survey (76805) – do not require prior authorization. Any additional ultrasounds will require prior authorization.

    Non-Obstetric Ultrasounds
    The first ultrasound for any one specific condition (e.g., pelvic ultrasound for pelvic pain, thyroid ultrasound for a thyroid mass, renal ultrasound for hematuria) does not require a prior authorization. Any additional ultrasound for the same condition will require prior authorization.

    PT/OT/ST
    Prior authorization is not required for the first six visits within the benefit period. Visit seven and beyond will require prior authorization. Please refer to the specific program benefits for limitations.

    Sleep Study Supplies
    Prior authorization is required every three months.

    Out-of-network services or services rendered by a non-participating physician or provider continue to require prior authorization. Participating Affinity providers must refer to in-network providers and/or render services in in-network facilities.

    All admissions through the emergency departments require notification within 24 hours of the admission in order to obtain authorization for continued inpatient stay.

    For an authorization form, click here: All Authorization Forms

    APPEALS/GRIEVANCES
    As an additional reminder, all appeals should contain a cover letter or memo clearly stating the reason for the appeal and the rationale for why Affinity should reconsider its position. Documentation (if necessary) should be included to support the rationale stated in the letter. If a claim was submitted and denied, a copy of the claim and/or explanation of payment should be included with the submitted material. If numerous pages are attached to the letter, please ensure you have tabbed or referenced the key information supporting your appeal. Affinity will make its decision based upon solid information that is concisely supported. If, when the appeal is filed, the information needed for reconsideration is not readily available, then Affinity will, in all likelihood, uphold its original determination.

    Appeal support should follow the original reason for denial. If a claim was originally denied because of lack of authorization, the appeal received from the provider should include rationale for why no authorization was requested rather than medical necessity information. Administrative denials cannot be ‘turned into’ medical necessity appeals.

    HIGH DOLLAR CLAIMS
    Effective July 1, 2017, Affinity may request medical records or itemized bills for certain high dollar claims with amounts paid outside of the DRG base rate. If additional materials are needed for review, Affinity will deny the claim for an itemized bill and/or medical record. Additional materials should be included with a corrected claim and sent to Affinity as a resubmission. This will ensure all materials are correctly sent to the proper person for prompt review and payment.