Coverage Decisions

Overview of Utilization Management Program

Utilization Management (UM) Review

Utilization Review is a check to see if healthcare services and treatment plans are covered, necessary, and appropriate. Ochsner Health Plan does different types of reviews:

Pre-service Review – This happens before a member gets care or services to see if the proposed services (like hospitalization) are appropriate and covered by the member’s plan.
Concurrent Review – This review checks if an ongoing treatment should continue while a member is receiving care.
Post-service Review – This happens after a member gets care or services to see if the care was appropriate and covered by the member’s plan.

Utilization Management Criteria

The Evidence of Coverage (EOC) Benefit Booklet is the contract for coverage of the healthcare services that an individual self-purchased. Ochsner Health Plan provides a variety of benefit plans in order to meet the needs of our members.

Some benefits are required by law to be offered, and some services are not offered for various reasons. The primary purpose of the Utilization Management (UM) Program is to manage services according to the terms contained in the EOC/Benefit Booklet and Medicare Guidelines. The medical necessity of the service is determined by Ochsner Health Plan medical staff with input from the member’s physician(s).

Ochsner Health Plan’s UM clinicians apply objective and evidence-based criteria and take individual circumstances and the local delivery system into account when determining the medical appropriateness of health care services.

Clinical, medical necessity reviews and associated determinations are based on hierarchically ranked, data-based, clinically focused resources. Within the electronic medical record, the resources range from Federal/State authorization requirements, InterQual criteria as appliable by delegation contract, and proprietary criteria developed internally at Ochsner Health Plan by industry-leading care physician experts.

Utilization Nurses and Medical Directors use the guidelines to help determine the medical necessity of requested services. Ochsner Health Plan’s clinical criteria hierarchy in order includes:

National Coverage Determinations (NCDs)
Local Coverage Determinations (LCDs)
State and Federal mandates, requirements, and care administration guidelines
InterQual Care Guidelines (link)
Applicable Medical and Clinical Policies

When developing Ochsner Health Plan’s own Clinical Medical Policies (in the absence of Medicare guidance) Evidence-Based Medicine (EBM) is utilized in the decision-making process. Evidence-Based Medicine is the conscientious and judicious use of well-tested, clinically reliable medical data in making decisions about the care of individuals. The practice of EBM typically means integrating clinical expertise with the best available external clinical evidence from systematic research.

Utilization Management Decisions

The criteria are just guidelines. All coverage denials are made by Ochsner Health Plan Medical Directors. Decisions on utilization management, including formulary coverage, are based only on the appropriateness of care and services and the EOC/Benefit Booklet. No one gets paid based on the use of services or denials. Ochsner Health Plan does not offer incentives or rewards to those conducting utilization review.

Utilization Management Staff Availability

We want members to get the right services and check for under-use, over-use, and misuse. Individual coverage requests or reviews are discussed with the doctors/providers making the request for a member. Ochsner Health Plan UM staff are available by phone 7 days a week at (toll free) 833-777-0933, or by appointment to discuss UM and/or coverage decisions, including benefits, guidelines, criteria, or processes. The number is covered after-hours by an on-call nurse with access to a Plan Medical Director. UM staff will identify themselves and provide their name and title when calling or returning calls to members. Language services are free for members upon request through bilingual staff or an interpreter to discuss utilization management decisions. TTY services are available for persons with hearing or speech difficulties by calling 833-844-7788.

Appeal of an Adverse Utilization Review Decision

A member, their representative, or their doctor can appeal a final utilization management denial, including the right to an independent external review. Appeal rights, including expedited appeals, reconsideration rights, and/or Independent Review Organization (IRO) options, and instructions on how to file an appeal are always provided with any denial issued by Ochsner Health Plan. Members can review the criteria by calling 833-777-0933. Questions or requests related to any case-specific guidelines used in making a benefit coverage decision can be directed to the UM Management team at the above numbers.

Medical and Part B Prescription Authorizations

For certain medical services and prescriptions under Medicare Part B, your provider needs approval from Ochsner Health Plan before your plan can cover the costs. For prescriptions under Part D, visit the Member Resources page.

Does this service require preauthorization?

For certain medical procedures, services, or medications, your doctor or hospital needs advanced approval before your plan covers any of the costs. Visit the preauthorizations list online. Contact us with questions about “preauthorization” and find out if the services you need are covered in your Ochsner plan.

Medicare members

Call the number on your member ID card to determine what services and medications require authorization.

Current preauthorization lists (Effective January 1, 2025)

We have updated our preauthorization list for Ochsner Health Plan’s Medicare Advantage Plans.

Please note that the term “preauthorization” (prior authorization, precertification, preadmission), when used in this communication, is defined as a process through which the physician or other healthcare provider is required to obtain advance approval from the plan as to whether an item or service may be covered.

The list details services and medications (i.e., medications that are delivered in the physician’s office, clinic, outpatient or home setting) that require preauthorization prior to being provided or administered. Services must be provided according to Medicare coverage guidelines, established by the Centers for Medicare & Medicaid Services (CMS). According to the guidelines, all medical care, services, supplies and equipment must be medically necessary. You can review Medicare coverage guidelines here.

Investigational and experimental procedures and devices usually are not covered benefits. Please consult the patient’s Evidence of Coverage or contact Ochsner Health Plan for confirmation of coverage.

Please note that certain services may not be covered under the member's plan.

Important notes:

All Ochsner MA plans – For procedures or services that are investigational or experimental (or that may have limited benefit coverage), or to learn if Ochsner will pay for a service, you can request an ACD on behalf of the patient prior to providing the service. You may be contacted if additional information is needed.
To prevent disruption of care, Ochsner Health Plan does not require prior authorization for basic Medicare benefits during the first 90 days of a new member’s enrollment for active courses of treatment that started prior to enrollment. Ochsner may review the services furnished during that active course of treatment against permissible coverage criteria when determining payment. To ensure appropriate claim payment please include the appropriate modifier or include medical records with evidence that the member is in an active course of treatment.

Please note that urgent/emergent services do not require referrals or preauthorization.

Not obtaining preauthorization for a service could result in financial penalties for the practice and reduced benefits for the patient based on the healthcare provider’s contract and the patient’s Certificate of Coverage. Services or medications provided without preauthorization may be subject to retrospective medical necessity review. We recommend that an individual practitioner making a specific request for services or medications verify benefits and preauthorization requirements with Ochsner Health Plan prior to providing services.

Information required for a preauthorization request or notification may include, but is not limited to, the following:

Member’s Plan ID number, name and date of birth
Date of actual service or hospital admission
Procedure codes
Date of proposed procedure (if applicable)
Diagnosis codes (primary and secondary)
Service location
Inpatient (acute hospital, skilled nursing or hospice)
Outpatient (telehealth, office, home, off-campus outpatient hospital, on-campus outpatient hospital or ambulatory surgery center)
Referral (office, off-campus outpatient hospital, on-campus outpatient hospital, ambulatory surgery center, other)
Tax Identification Number (TIN) and National Provider Identifier (NPI) number of treatment facility where service is being rendered
TIN and NPI number of the provider performing the service
Caller/requestor’s name/telephone number
Attending physician’s telephone number
Relevant clinical information
Discharge plans

Submitting all relevant clinical information at the time of the request will help expedite determination. If additional clinical information is required, an Ochsner Health Plan representative will request the specific information needed to complete the authorization process.

How to request preauthorization:

Except where noted via links on the following pages, preauthorization requests for medical services may be initiated:

Fax: 833-947-7577
Toll Free: 833-777-0933

Please note: Online preauthorization requests are encouraged. For certain PAL services requested via the online portal, healthcare providers have an option to complete a questionnaire. Answers to the questionnaire could lead to real-time approval. If approval is not provided immediately, the information on the questionnaire may help Ochsner Health Plan with the review.