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.
- Prior Authorization List
- Referral/Prior Authorization/Notification Request Form
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.