Authorization

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.