How We Approve Coverage for Care

INTotal Health has procedures to guide us in making decisions about using your health care benefits. Our goal is to assure that you use your benefits appropriately in an efficient, quality-driven, cost-effective manner.

Approval for Services
Many services require approval before you can receive the service. This is called pre-service approval. For example inpatient hospital care that is not an emergency requires approval. This means your physician must call us for approval prior to admitting you to the hospital. It is the physician’s responsibility to obtain approval for services when indicated. If approval is not granted, the process to appeal the decision will be explained.

Some services do not require pre-service approval. These include:

• Emergency services.
• Family planning services.
• Basic prenatal care in-network.
• Sexually transmitted disease services.
• HIV testing and counseling.
• Office visits to Primary Care Practitioners.

If you are hospitalized or if you are receiving care over a long period of time, we will review your condition on a regular basis to determine if your care continues to be covered.  To be covered your care must continually meet criteria for the level of care you are receiving.  This process of ongoing review is called concurrent review.  Our staff will discuss the status of your condition with your provider.  If we do not approve your provider’s request for continued care in the hospital or other setting, the process to appeal the decision will be explained to your provider and to you.

In some cases you may obtain care and ask us to pay for it after you have received the care and services.  We will review the situation and make a decision.  This is called post-service approval.  If the information about the situation does not meet our criteria we will not approve the request for payment.  We will tell your provider and you about the process to appeal this decision.

Complicated Health Conditions
If you have a complicated health condition, you may be eligible for our Case Management Program.  If you qualify a case manager will be assigned to you to help you get the care you need.  The Case Manager will coordinate your care with different providers and help you obtain medications and medical supplies as well as tell you about other resources for your condition.  You may refer yourself to our Case Management Program by calling 1-855-323-5588.

Practitioner and Provider Availability
INTotal Health has a large Provider Network.  There are many different types of facilities and practitioners.  We have a Provider Directory to help you select the practitioner and facility that meets your needs.  We encourage you to select a primary care practitioner (PCP) to oversee and coordinate your care.  We have standards for how many practitioners and facilities we need in our Network and standards for what types of practitioners and facilities.  We measure at least annually to be sure we meet those standards.  You do not need prior authorization to see a primary care practitioner.  You do not need a referral to see a specialist but you should tell your primary care practitioner when you see a specialist.  Your primary care practitioner can also arrange a specialist visit.

Potential Restrictions
For some services such as physical therapy, speech therapy, chiropractic care there may be a defined number of visits per year.

Some restricted services include:

• Abortion services
• Hearing aids for members 21 years of age and older.
• Home health personal care services.
• Custodial care.

For more information about our utilization procedures, our provider and practitioner network and potential network, service or benefit restrictions, please contact Customer Services at 1.855.323.5588.  We will provide our Provider Directory information and schedule of benefits, upon request.