AlohaCare requires prior authorization for certain services and drugs for our members. Look below for more information about what services and medications require prior authorization and how the process works.
Medical Necessity Criteria - Administration of QUEST Integration Benefits
In the administration of QUEST Integration benefits, AlohaCare requires that certain services be prior authorized and/or undergo concurrent or retrospective review. The reviews ensure that the services are covered health interventions and meet the definition of medical necessity under § 432E-1.4 of the Hawaii Revised Statutes. See Appendix C in the AlohaCare Provider Manual for the text of HRS § 432E-1.4.
During each review, a decision is made regarding the medical necessity of services being requested, prescribed or rendered. AlohaCare’s determination is based on the medical information submitted by the provider, or available in medical records. AlohaCare uses nationally developed clinical criteria (such as InterQual® Level of Care Criteria, InterQual® Imaging Criteria, InterQual® Procedures Criteria, InterQual® Level of Care Behavior Health Criteria, and American Society of Addictive Medicines) for systematic medical necessity determinations.
For prior authorization requests or concurrent review, AlohaCare requests that the treating physician or other licensed provider supply additional information to assist AlohaCare in the determination of medical necessity. For retrospective review, payment denials may be determined by the review of records received. In these cases, providers have the opportunity to submit additional information and request reconsideration through the grievance and appeals process.
Peer review is available if the provider and AlohaCare’s Medical Director do not agree on whether a health intervention is medically necessary.
AlohaCare’s decision is a determination of benefit coverage and payment only, and not a determination of whether services should be rendered. The decision to provide medical services is made by the provider using his/her professional judgment.
Some benefits have established limits for the benefit year(s). The benefit year runs January 1st through December 31st.
AlohaCare will make the Medical Necessity criteria available, upon request. Please contact us if you wish to access the criteria.
Utilization management (UM) is an important component of evaluating the necessity, appropriateness and efficiency of health care services in accordance with established guidelines and criteria. Medical management (MM) strengthens the partnership between AlohaCare and our providers by establishing medical protocols that ensure the delivery of high quality health care with the goal of optimizing health outcomes for our members. Through UM and MM activities, AlohaCare works with our network providers to advocate, develop and implement quality initiatives and interventions to improve the health and well-being of our members. AlohaCare makes Utilization Management decisions based solely on appropriateness of care and service and member eligibility for plan benefits and coverage. AlohaCare does not specifically reward providers, staff, or any other individuals, for issuing denials of coverage, nor does it encourage or offer any financial incentives to individuals who are responsible for making UM decisions that result in underutilization.
Questions? Contact the UM staff:
Call 808-973-1657 or toll free at 1-800-434-1002
Monday through Friday, 8 a.m. to 5 p.m.
If a member needs help understanding their benefits or how to discuss UM issues, please call us. When you call us, you can ask to talk to someone in the language the member speaks. AlohaCare offers free interpreter services for our members. If you need an interpreter, call Member Services at 973-0712 (Oahu) or toll-free at 1-877-973-0712. If you require assistance due to a hearing impairment, call 1-877-447-5990.