How We Make Coverage Decisions

May 17, 2017
How We Make Coverage Decisions

We work to make sure our members get the right healthcare in every care setting. We support proper care decisions based on medical necessity and the member’s specific health plan. When a service needs pre-authorization, our Medical Director and clinical staff follow QualChoice Medical Coverage Policies. They also follow the peer-reviewed and nationally noted guidelines of MCG Health, LLC.


Utilization management means the review by our Medical Director and clinical staff of things like:

  • Time frame of care given
  • Number of days in hospital
  • Amount of medicine given
  • Recovery time

Reviewing these things helps patients get the right services at the right time, and for the right length of time. It also ensures that the care being given is needed, and no un-needed services are being performed. Utilization management ensures continuous review of our members’ care.

We affirm the following:

  • Utilization management decisions are based only on what care and services are needed and the member’s coverage.
  • We do not reward providers or others for denying coverage of service or care.
  • We do not offer a financial bonus for under-utilization.

To give the best care possible and to use healthcare dollars wisely, the care being given must:

  • Be medically necessary
  • Be appropriate
  • Follow clinical best practices

Some types of services must be approved before being performed (pre-authorization). The list of those services may change from time to time. Here are some examples:

  • Admission to an inpatient facility or partial hospital unit
  • Referral to an out-of-network provider
  • Extra OB ultrasounds (up to three covered per pregnancy without pre-authorization)
  • Home health care or infusion services, hospice (inpatient or outpatient)
  • Organ transplant (inpatient or outpatient)
  • Advanced imaging (outpatient)
  • Specialty medications (Tier 5)
  • Genetic testing such as for hereditary diseases or cancer; in- and out-of-network pre-authorization required

Getting pre-authorization:

  • Your in-network provider must get any needed pre-authorization.
  • If using an out-of-network provider, make sure they get any needed pre-authorization.
  • If you’re traveling and using the QualChoice National Network, you must get any needed pre-authorization.