Predetermination Requests and Process

Predetermination Requests

• Predetermination is a review of services to determine coverage in accordance with the summary plan document.
• It's requested by the member or provider and only applies to Outpatient and DME services.

Predetermination Process

• Complete a member search and verify HIPAA by ensuring patient's name, DOB, and Member ID or complete address.
• Verify benefit plan requirements based on the service required.
• Check if prior authorization is required and begin the prior authorization request in Aerial if necessary.
• Intake will verify if Predetermination is recommended per code look up tool and/or HPDB.

Code Look Up Tool

• Check the Code Look Up Tool link: http://umr-automations.uhc.com/umrcodelookup/codesearch.aspx
• If not on Code Look Up Tool, check HPDB located in CPS/Jacada.

Predetermination Review

• Predetermination will only review if the service has not taken place and will not back date for ongoing services.
• Reconsiderations are allowed if a case is denied, and providers may submit additional clinical for review.

TAT and Appeal Rights

• TAT (Turn-Around-Time) is 15 days for all Predeterminations.
• There are no appeal rights or P2P (Peer-to-Peer) requests for Predeterminations, except for TRH, WCA Groups, and Northern Arizona Healthcare.

DME Predeterminations

• DME predeterminations are determined by dollar threshold of 500permonthrental/500 per month rental/500permonthrental/1,500 purchase.
• Prosthetics are reviewed if over the dollar threshold, and Orthotics/Braces check DME tab under HPDB if med nec is recommended.
• No Predetermination is needed for any A coding regardless of cost.

Diagnosis Selection Search Tool

• Use the Diagnosis Selection Search tool when services are conditional on Code Lookup Tool.
• Example: Remicade on the Code Lookup Tool when listed as Conditional.