Policies, Guidelines & Forms
Prior Authorization
What is a Prior Authorization or Pre-authorization?
Certain medical procedures and medications require approval before you will be able to receive treatment. The prior approval process is called pre-authorization, or prior authorization (PA).
Prior authorization allows for a personal review of your treatment within the context of your existing health issues, medications and treatments.
Reasons for Prior Authorization include:
- Review of treatment options and any related risks to the treatment
- Manage Costs - Prior Authorization helps ensure that you have insurance coverage for a procedure, treatment or service
- Avoid excess and waste - utilization management review for inappropriate or unnecessary medical treatments
Procedures, Products and Treatment requiring Prior Authorization
- A current list of Medical Services requiring Prior Authorization can be viewed on the Medical Services requiring Prior Authorization
Upcoming Changes to Codes Requiring Prior Authorization
No upcoming changes to codes requiring prior authorization (PA) at this time. Please check back later.
Prior Authorization (Medical Utilization Management Review) & Notifications
In order to help you assist patients in a timely and efficient manner; please use the Prior Authorization Request Application. The Prior Authorization application replaces all previous and existing U of U Health Plans Medical Utilization forms.
Prior Authorization requests via Fax
Updated: If you need to submit Prior Authorization requests via Fax, please use the updated number(s)
| Prior Authorization Request | Fax Number |
|---|---|
| Prior Authorization | 801-213-1358 |
| Inpatient Notification, SNF & Rehab | 801-213-2132 |
| Behavioral Health & Substance Use Treatment | 801-213-2132 |
| Appeals | 801-587-9985 |
| Medical Pharmacy | 801-213-1547 |
Updated: Please note the current PDF forms are suitable for faxing
Peer to Peer Information and Form
Peer to Peer Review
A peer-to-peer (P2P) review is a conversation over the phone between a licensed University of Utah Health Plan physician reviewer and the physician or treating practitioner who requested the authorization. A P2P conversation is not an additional level of review and is not an appeal. It is not intended to be a mechanism to overturn the denial.
The main purpose of a P2P is to better understand the rationale for the denial based on our medical polices and criteria used.
P2P conversations must occur prior to any appeal submission and are intended for services denied for medical necessity or investigational reasons. A P2P is not to be used to discuss situations where services were denied for any other reason.
To ensure that the requesting provider has received the rationale for the denial and has been informed of the criteria or medical policy used, a P2P must be requested:
- After the provider has received the determination letter
- Within 7 calendar days from the date of the determination letter
If you have questions regarding our P2P process, please contact our Customer Service department at:
- Medicaid Plans: 833-981-0212 (toll free)
- Individual and Business Plans: 833-981-0213 (toll free)
If the provider disagrees with our decision or has additional information to submit, the provider may submit an appeal following the P2P process.
Once a P2P form has been received, the requesting practitioner can expect a call to schedule the P2P within 2 business days
Peer-to-Peer (P2P) Process Frequently Asked Questions (FAQs)
| What is a Peer-to-Peer (P2P)? | The peer-to-peer (P2P) process provides an opportunity for a member’s doctor to discuss the rationale and criteria used to make a specific authorization determination. It is not another level of review and not meant to take the place of an appeal. |
|---|---|
| What is the difference between a P2P and an appeal? |
A P2P is a conversation between the requesting doctor or treating practitioner and a Health Plan Physician reviewer about a denial decision made for an authorization request. The purpose is to clarify why something was denied, but not intended to change the decision. An appeal is a formal request for a second review of the authorization. The appeal is to request a different determination. |
| How can I schedule a P2P? |
The requesting provider may fill out a P2P form here. You may also reach out to our customer service department with questions. |
| When can I request a P2P? | A P2P is designed to be after the original coverage determination was made, but prior to an appeal. You have 7 calendar days from the date of the original determination to request the P2P. |
| How many P2P conversations can I request? | A P2P is offered one time per request determination. After the P2P is complete, if you do not agree with the original determination an appeal would be the appropriate step. |
| Who is able to request a P2P conversation? | The original requesting provider or a designated person from the provider’s staff can request a P2P. |
| Who takes part in the P2P discussion? | Only the original requesting provider or treating practitioner takes part in the conversation. We do not allow other office or non-medical staff to participate in the conversation with our physician reviewer. |
| How long does it take to schedule a P2P? | Once the P2P form has been submitted, we typically respond back with scheduling options within 2 business days. The appointment time will vary depending on physician availability, but we make every effort to schedule them as quickly as possible. |
| I have been told my case is not eligible for a P2P, why is this? |
P2P are allowed for pre service denials, concurrent reviews, and post service denials when the notification letter indicates it as an option. P2P are intended for services denied for not being medically necessary or investigational. It must be requested before an appeal. It also must be requested within 7 calendar days of the original notification date. Most often cases are not eligible for P2P because they fall outside the approved timeframe window, an appeal has already been submitted, or the original request was denied for reasons other than medical necessity. These decisions must be appealed. |
| How to I request an Appeal? |
You will need to fill out an appeal form. The instructions were included in the original determination letter. You may find the appeal form on our website here: Appeal Form You may also call customer service during business hours, and they can help you submit the appeal. |
| Can I request a P2P on an urgent case? |
A peer to peer is not an additional level of review, so there is no Urgent Peer to Peer. If you would like a second review done on a case that is urgent, you may request an expedited appeal. Note: Expedited requests should be reserved for situations where application of the time frame for making routine care determinations could seriously jeopardize the life, health or safety of the member. It includes situations where lack of the requested treatment would subject the member to severe adverse health consequences. |
| If I withdraw my appeal, can I do a P2P? | Yes, an appeal is a formal request for a second review of the authorization. If you withdraw your appeal, you are eligible for the Peer to Peer. You may re-submit your appeal after the peer to peer. |
| If the member is still in the hospital, can I request a P2P while they are admitted? What about discharges over the weekend or on a holiday? | Yes, will respond within 2 business days of the request to set up a time for discussion. |
| Can the original authorization decision be changed or approved as a result of the P2P process? | The purpose of the P2P is to provide an explanation of the denial. A P2P conversation does not typically result in overturning the original decision. |
Medical Documentation Submission Form
Along with the missing documentation, please use the form for MDOC claim denials.
Complete the form online, upload the required documentation files, and click “Submit,” instead of faxing the form.