Back Utilization Management
To request for Service Authorization, please download the form here .
Utilization management (UM) is a process to manage health care costs through decision-making techniques on a case-by-case assessment of the appropriateness of care*. Through the UM process, Solis Health Plans works together with your primary care provider to plan individualized care that is appropriate as well as cost effective. The materials provided to you by Solis Health Plans are guidelines used to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your plan’s contract.
Clinical guidelines approved by Solis Health Plans include internally developed clinical guidelines, InterQual criteria, MCG (Milliman Care Guidelines), Hayes technology reports, National Coverage Determinations (NCD) and other evidence-based resources. Clinical guidelines are evaluated and updated at least annually and are available to both members and providers.
Clinical guidelines are complex and intended for use by healthcare professionals. They are not intended to provide medical advice or medical care. Medical advice and care should be discussed with the treating provider or primary care provider. As noted in the disclaimer below, coverage is subject to the terms and conditions of your benefit plan and state and federal law. To confirm benefit coverage or to request a copy of a clinical guideline used to support medical necessity decisions, please contact Member Services by calling 844-447-6547.
Disclaimer: Clinical guidelines are developed and adopted to establish evidence-based clinical criteria for utilization management decisions. Solis Health Plans may delegate utilization management decisions of certain services to third-party delegates, who may develop and adopt their own clinical criteria. Clinical guidelines are applicable to certain plans. Clinical guidelines are applicable to members enrolled in Medicare Advantage plans only if there are no criteria established for the specified service in a Centers for Medicare & Medicaid Services (CMS) national coverage determination (NCD) or local coverage determination (LCD) on the date of a prior authorization request. Services are subject to the terms, conditions, limitations of a member’s policy and applicable state and federal law. Please reference the member’s policy documents (e.g., Certificate/Evidence of Coverage, Schedule of Benefits) or contact Solis Health Plans at 844-447-6547. *Institute of Medicine Committee on Utilization Management by Third Parties: Controlling Costs, Changing Patient Care? The Role of Utilization Management. In Gray, B.H., and Field, M.J., eds. Washington, National Academy Press, 1989.
Determining Levels of Care and Coverage
Evaluation of care may be performed prior to receiving the care, also known as Preservice, while you are receiving the care, also known as Concurrent review, or after you have received the care, also known as Retrospective Review.
Concurrent Review
We may evaluate your care while you are in the hospital or receiving outpatient treatment. We aim to help make sure the person gets the right level of care, at the right time, in the right location, and at a reasonable cost. Through concurrent review, we determine if the person’s plan covers the treatment that is under review.
Concurrent review process includes:
- Collecting information from the care team about the person’s condition and progress.
- Determining coverage based on this information.
- Informing everyone involved in the patient’s care about the coverage determination.
- Identifying a plan that includes discharge and continuing care as early as possible within the stay.
- Ongoing assessment of the plan during the stay.
- Identifying members for referral to specialty programs inclusive of case management or disease management. Concurrent review may be done by phone, fax, or on-site at the facility.
Retrospective Review
Retrospective review is the process of determining coverage after treatment has been given.
Retrospective review process includes:
- Confirming a member’s eligibility and availability of benefits.
- Analyzing patient care data to support the coverage determination process
- Analyzing patient care data to support the coverage determination process
Retrospective review is available when precertification and notification requirements were met at the time the service was provided, but the dates of service do not match the submitted claim. Retrospective review is not available when claims are for elective ambulatory or inpatient services that required precertification and precertification did not occur before providing the service. If inpatient service required precertification but was rendered as an emergency service, notification is required within one business day of the admission date.
Frequently Asked Questions (FAQs)
You have the right to ask Solis Health Plans to pay for items or services you think should be covered, also called a coverage decision.
If you are a Medicare member, this is called a request for "organization determination.” An organization determination (referred to here as a coverage decision) is a decision Solis Health Plans makes about your benefits and coverage and whether we will pay for the medical services you or your doctor have requested. You can also contact us to ask for a coverage decision before you receive certain medical services. You might want to ask us to make a coverage decision beforehand if your doctor is unsure whether we will cover a particular medical service or if your doctor refuses to provide medical care you think you need. You, your representative, or your doctor can ask us for a coverage decision by calling, writing, or faxing your request to us.
Make a free call to 1-844-447-6547. You can call us Monday through Friday, from 8 a.m. - 8 p.m. (Eastern Standard Time) between April 1st -September 30th or seven days a week from 8 a.m. – 8 p.m. from October 1st to March 31st. If you reach our automated system after hours or on holidays, please leave your name and telephone number, and we’ll call you back by the end of the next business day. Member Services also has free language interpreter services available for non-English speakers. TTY 711 Calls to this number are free.
This number requires special telephone equipment and is only for people who have difficulties hearing or speaking.
Fax: 1-833-210-8141
Contact us by fax should you have an expedited coverage request.
Write:
Solis Health Plans
9250 NW 36th St., Suite 400
Doral, FL 33178.
We will use “standard” deadlines unless we have agreed to use the “expedited” (fast) deadlines.
A standard coverage decision means we will give you an answer within 14 days of receiving your request.
If you think your health could be seriously harmed or that you could lose your ability to function by waiting the standard 14 days for a decision, you can ask for an “expedited” (fast) decision.
We will give you an answer within 72 hours after we receive your request for a fast coverage decision.
To get a fast coverage decision, you must meet two requirements:
- You must be asking for coverage for medical care you have not yet received. (You cannot get a fast coverage decision if your request is about payment for medical care, you have already received.)
- You must make a fast decision because using the standard deadlines could cause serious harm to your health or hurt your ability to function.
If your doctor tells Solis Health Plans that your health requires a “fast coverage decision” also known as an expedited request, we will automatically agree to give you a fast coverage decision.
If you ask for a fast coverage decision on your own, without your doctor's support, we will decide whether your health requires that we give you a fast coverage decision.
If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will send you a letter that says so and we will use the standard deadlines instead.
We can take up to 14 more calendar days to make either a standard or fast decision if you ask for more time or if we need information, such as medical records from out-of-network providers, that may benefit you. This is called an extension. If we decide to take extra days to make the decision, we will tell you in writing.
If you believe we should not take extra days, you can file a “fast complaint”, also known as an expedited grievance, about our decision to take extra days. When you file an expedited grievance, we will give you an answer to your complaint within 24 hours.
If we do not give you our answer within the standard or fast time (or if there is an extension at the end of that period), you have the right to appeal. You also have the right to file an appeal if you disagree with our coverage decision.
In some cases, we might decide a service is not covered or is no longer covered by your plan. If we say “no” to part or all of what you requested, we will send you a detailed written explanation as to why we said “no” and instructions on how to appeal our decision.
For some types of items or services, your doctor may need to get approval in advance from our plan (this is called getting "prior authorization"). Those services that require advance approval are included in your Evidence of Coverage.