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Utilization Management

PW_E180865
Utilization Management  
A Pre-certification or Predetermination Tool is used by the provider to submit clinical information for an authorization request (precert or predetermination). If a provider uses this tool, chart records and letters of medical necessity will not be needed unless the tool is selected for auditing.  
The Clinical Data Submission Tools on this site may be used to submit clinical information for either a pre-service review (pre-certification or pre-determination) or Post Service review, including pre or post claim submission.  
The patient's demographic information should be completed in the first section of the tool.
The patient's clinical information should be completed in the second section of the tool by checking the series of boxes all that applies to the patient's medical condition.
After completion of the Clinical Data Submission Tools-, the information should be submitted to the Utilization Management address or fax number referenced in this contact list. If you would like to submit the tool via e-mail, please contact the Utilization Management Department to have the tools emailed to you for submission electronically.  If you are not set up for secure E-Review and would like to be, please contact the Utilization Management Department.
The information, when filled out completely, should provide Utilization Management the necessary clinical information, including condition and history, to determine if the case meets the medical necessity criteria.
In some select situations, you may be asked to submit medical records (such as random auditing), or additional information such as photographs or visual fields, as an example.
Please make sure that physician or physician representative signs and checks the attestation at the bottom of the Clinical Data Submission Tool before submitting for review.
 
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Ancillary  
Cosmetic and Reconstructive Services: Skin Related MP-ANC-07
Cosmetic and Reconstructive Services of the Trunk and Groin ANC.00009
 
Durable Medical Equipment  
Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD) CG-DME-07
Electrical Bone Growth Stimulator MP-DME-04
Oscillatory Devices for Airway Clearance including High Frequency Chest Compression (Vest Airway Clearance System) and Intrapulmonary Percussive Ventilation (IPV) DME.00012
Powered Wheeled Mobility Assistance Device CG-DME-31
Ultrasound Bone Growth Stimulation DME.00027
Ultraviolet Light Therapy Delivery Devices for Home Use DME.00036
Vacuum Assisted Wound Therapy MP-DME-09
Wheeled Mobility Devices: Manual Wheelchairs-Ultra Lightweight CG-DME-33
 
Genetics  
Cardiac Ion Channel Genetic Testing GENE.00007
Diagnostic Genetic Testing for Potentially Affected Patient MP-GENE-13
Gene Expression Profiling for Managing Breast Cancer Treatment MP-GENE-11
Genetic Testing for Breast and/or Ovarian Cancer Syndrome GENE.00029
Genetic Testing for Cancer Susceptibility GENE.00001
Genetic Testing for Colorectal Cancer Susceptibility GENE.00028
Genetic Testing for Endocrine Gland Cancer Susceptibility GENE.00030
Genotype Testing for Genetic Polymorphisms GENE.00010
Preconceptional or Prenatal Genetic Testing of a Parent or Prospective Parent GENE.00012
 
Laboratory  
None  
 
Medicine  
Diaphragmatic/Phrenic Nerve Stimulation MED.00100
Hyperbaric Oxygen Therapy MP-MED-05
Multiple Sleep Latency Testing (MSLT) and Maintenance of Wakefullness Testing (MWT)- CG-MED-43
Spinal Manipulation Under Anesthesia MED.00079
Treatment of Hyperhidrosis MED.00032
Wearable Cardioverter Defibrillators MED.00055
 
Orthotics-Prosthetics  
Microprocessor Controlled Lower Limb Prostheses OR-PR.00003
Myoelectric Upper Extremity Prosthetic Devices CG-OR-PR.05
 
Radiology  
Modulated Radiation Therapy (IMRT) RAD.00041
Brachytherapy for Oncologic Indications RAD.00014
Intraoperative Radiation Therapy RAD.00017
Neutron Beam Radiotherapy RAD.00047
Radioimmunotherapy Somatostatin Receptor RAD.00031
Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) MP-RAD-11
Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule RAD.00030
 
Rehabilitation  
None  
 
Surgery  
Autologus, Allogenic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting SURG.00011
Blepharoplasty - CG-SURG-03
Bone Anchored Hearing Aids SURG.00020
Breast Procedures including Reconstructive Surgery, Implants and Other Procedures MP-SURG-23
Cardiac Resynchronization Therapy with or without an Implantable Cardioverter (CRT/ICD) for Treatment of Heart Failure SURG.00064
Carotid, Vertebral, Intercranial Angioplasty MP-SURG-01
Cochlear and Auditory Brainstem Implants SURG.00014
Cryosurgical Ablation of Tumors outside the liver SURG.00025
Deep Brain Stimulation SURG.00026
Endovascular, Endoluminal Repair of Aortic Aneurysms SURG.00054
Endothelial Keratoplasty SURG.00108
Fetal Surgery for Prenatally Diagnosed Malformations SURG.00036
Functional Endoscopic Sinus Surgery CG-SURG-24
Gastric Electrical Stimulation SURG.00046
Implantable Cardioverter Defibrillator (ICD) SURG.00033
Implantable Infusion Pumps MP-SURG-68
Implanted Spinal Cord Stimulators MP-SURG-60
Intraocular Anterior Segment Aqueous Drainage Devices MP-SURG-103
Locally Ablative Techniques for Treating Liver Malignancies MP-SURG-65
Mandibular/Maxillary (Orthognathic) Surgery SURG.00049
Mastectomy for Gynecomastia MP-SURG-85
Maze Procedure- CG-SURG-05
Oral, Pharyngeal and Maxillofacial Surgery for Treatment of Obstructive Sleep Apnea SURG.000129
Panniculectomy, Abdominoplasty SURG.00048
Penile Prosthesis Implantation CG-SURG-12
Percutaneous Neurolysis for Chronic Back Pain SURG.00066
Percutaneous Spinal Procedures (Vertebroplasty, Kyphoplasty and Sacroplasty) SURG.00067
Radiofrequency Ablation for the Treatment of Barrett's Esophagus SURG.00106
Radiofrequency Ablation for Trigeminal Neuralgia SURG.00090
Radiofrequency Ablation Outside the Liver SURG.00050
Reduction Mammoplasty MP-SURG-86
Refractive Surgery SURG.00009
Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention SURG.00117
Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
Septoplasty CG-SURG-18
Surgery for Clinically Severe Obesity MP-SURG-24
Temporamandibular Joint Dysfunction (TMD), Temporomandibular Joint Syndrome (TMJ), Craniomandibular Disorder (CMD) SURG.00009
Tonsillectomy for Children CG-SURG-30
Total Ankle Replacement SURG.00081
Transcatheter Closure of Cardiovascular Defects SURG.00032
Transcatheter Heart Valves SURG.00121
Transcatheter Uterine Artery Embolizatoin CG-SURG-28
Treatment of Osteochondral Defects SURG.00093
Treatment of Varicose Veins SURG.00037
Treatments for Urinary Incontinence and Urinary Retention MP SURG.00010
Vagus Nerve Stimulation Therapy SURG.00007
 
Transplant  
None  
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