BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...

BadgerCare Plus & Medicaid SSI Provider Manual - GHC of Eau Claire May 2012
SECTION 9 –AUTHORIZATION GUIDELINES
Authorization for services does not guarantee payment for services. Payment for services is dependent on other
non-medical criteria such as the benefits associated with a member’s specific plan and eligibility issues.
Authorization guidelines must be followed even if GHC is secondary to another insurance plan, including
Medicare.
Retroactive event authorizations for services will not be granted unless there is a compelling reason for
consideration. At no time will a retroactive event authorization be approved for a time span greater than
two weeks prior to the receipt date.
Authorization forms are located in Appendix A of this manual. Behavioral Health authorization forms are located in
Appendix B of this manual.
All Facility Admissions
Prior authorization is required for all facility admissions including:
non-emergent hospital admissions
rehabilitation facility admissions
skilled nursing facility admissions
sub-acute care admissions
behavioral health admissions
swing bed admissions
Additional clinical information may be needed to assess length of stays that are prolonged after the initial length of
stay authorization approval (Concurrent Review). Use the ‘Notification Request for Admission Form’ located in
Appendix A.
For Emergency Admissions, next business day notification and notification of discharge date at time of
discharge are required. Additional clinical information may be needed to assess length of stays that are
prolonged after the initial length of stay authorization approval (Concurrent Review). Use ‘Notification
Request for Admission Form’ located in Appendix A.
Alternative Medicine Services
Alternative medicine specialists including massage therapists, acupuncturists, and/or herbal therapists are noncovered
benefits for all plans. No services will be authorized or paid for.
Behavioral Health & Alcohol and Other Drug Abuse (AODA)
The behavioral health and AODA service areas of GHC are referred to as Region 1 and Region 2. When a primary
care provider or a member themselves, determines that behavioral health or AODA services (either inpatient or
outpatient) are needed, they must adhere to the following:
Region1 services are for BadgerCare Plus members who reside in the counties of Barron, Chippewa
and Eau Claire. These services are provided directly by Omne Clinic, Inc. who can be reached at
(800) 847-2144 to schedule services.
Region 2 services are for BadgerCare Plus members who reside outside of Barron, Chippewa and Eau
Claire counties and all GHC commercial and Medicaid SSI members. These services are not provided
directly by Omne. Members and the providers who serve them should contact Group Health
Cooperative’s Health Management Department at (800) 218-1745 for all authorization and referral needs.
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