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Specialty Referral Process (protocol 1)

Clinical Laboratory Services (protocol 2)

Use of Non-Participating Laboratory Services (protocol 2A)

Pre-Certification Process (protocol 3)

Concurrent Review Process (protocol 4)

Drug Prior Authorization (PA) (protocol 5)

Other UM Information:

Utilization Management Decisions
Pre-Certification Timeframes
Affirmative Statement
Telephone Access

Utilization Management Decisions

As a NHP participating provider, we would like to keep you informed on all Utilization Management (UM) criteria and the tools we use to help us best manage your patient's care. The criteria are available to practitioners and providers upon request. NHP currently utilizes the following criteria:

Milliman Care Guidelines, Ambulatory Care
Medicare - National Coverage Determinations
Medicare - Florida Medical Policy Procedures
Medicare Coverage Manuals
UnitedHealthcare Online

Pre-Certification Timeframes

To efficiently and appropriately process requests for procedures that require pre-certification, UM encourages our providers to submit information at the time service is requested. Be sure to provide all the necessary information with your request. With complete information, UM can process pre-certification requests within the guidelines below. Refer to the NHP pre-certification and referral list for a complete list of services requiring pre-certification. For “Urgent” requests, please call Medical Management at 1-800-550-5568.

If a request is received with insufficient information to make a determination, UM will contact our providers to submit the necessary information. In the event that our attempts to receive this information are unsuccessful, the member may be notified via mail of the specific information that is required to make the determination. This letter will, in turn, extend the timeframe in order to receive this required information. A decision due date will be included in this letter. If this requested information is not received by the decision due date, a decision will be made with the information that was made available to UM. Notification of the outcome will be sent to the member, PCP and requesting provider.

Affirmative Statement

Underutilization of health care and services poses a risk to the health and safety of NHP members. Underutilization could mean our members were not receiving proper preventative care needed to stay healthy. It could also lead to limited member access to out-patient/inpatient care and inappropriate emergency room use. As an NHP provider, you too should be concerned about the risks of under-utilization.

NHP encourages appropriate decisions on the coverage of care and services. NHP does not use incentives that encourage barriers to care and/or service, or that reward inappropriate restriction of care. Rather NHP encourages appropriate utilization while discouraging any underutilization.

NHP affirms the following:

Utilization management decision making is based only on appropriateness of care and services and existence of coverage,

NHP does not reward practitioners or other individuals conducting utilization review for issuing denials of coverage of service or care,

No incentives are offered to encourage underutilization.

Telephone Access

If you will like additional information or copies of specific criteria, please call our Utilization Management department at 800-550-5568.