Utilization review

To see if a prior authorization or pre-service review is required, check our code list or sign in to get member-specific information using the prior authorization tool.

You can submit a prior authorization for LifeWise individual plan members using the Identifi online submission tool. Sign in and submit a request with the member's ID number.

When registering, it takes 1-5 business days for LifeWise to authorize your use of the tool. Signing into our secure site automatically triggers the authentication process and you will receive a confirmation email once access is granted. If you need to submit a prior authorization during the waiting period, you can fax a prior authorization request using our request form to 888-613-1497. Be sure to include the needed supporting documentation (see our code list for details).

Sign in to the online prior authorization tool to get the status of a request. You can search for requests by reference number, requesting provider, or patient name. You can also edit a submitted prior authorization request in the tool.

For advanced imaging, prior authorization requests must go through Carelon Medical Benefits Management.

To request a prior authorization, register with Carelon and submit your request online or by phone at 866-666-0776. View our code list and the Carelon clinical appropriateness guidelines to assist you.

The following services are subject to review by Carelon:

• Genetic testing
• Imaging (CT scan, echocardiography, MRI, MRA, nuclear cardiology, PET scan)
• Radiation oncology
• Sleep study

The following services do not require prior authorization:

• Emergency room services
• Inpatient hospitalization
• Outpatient surgeries (hospitals and free-standing surgery centers)
• Observation stays

Servicing providers are strongly encouraged to verify that the prior authorization has been received before scheduling and performing services. In addition, imaging servicing providers must submit ordering/referring provider information, per guidelines from the Centers for Medicare and Medicaid Services (CMS), in boxes 17 and 17b on CMS-1500 forms.

Trying to see if a prescription medication requires prior authorization? Check out Drugs Requiring Approval .

For inpatient stays, you can fax the patient's hospital face sheet to our utilization management team at 888-613-1497 or you can submit an admission and discharge notification. You don’t need to send a hospital census. Submitting a face sheet or notification helps you get your claims paid correctly and on time.

If an emergency prevents you from getting prior authorization, you must notify us within 48 hours following onset of treatment, or as soon as is reasonably possible.

We know situations arise that can make it impossible for you to get prior authorization before treating a patient, or to notify us within 24 hours of admission. In these situations, please contact us before submitting a claim. Follow the recommended practices detailed in the extenuating circumstances policy so that the claim isn't automatically denied.

Sign in to Availity to check if a code needs review and to submit prior authorizations.

For general code information, use the code check tool in Availity in the LifeWise Payer Space in Resources or through Authorizations & Referrals > Additional Authorizations and Referrals. The code check tool doesn't provide member-specific information.

Sign in to Availity to submit prior authorizations.

To change an existing request, use the following forms, include the reference number, and fax to 800-843-1114. Check our code list for required supporting documentation.

Fax forms:

• General prior authorization request
• Durable medical equipment (DME) request
• Provider-administered infusion drugs request
• Out-of-network pre-authorization and exception request
• Transition of care
• Continuity of care

Definitions

Transition of care: If a member is undergoing treatment, but their current provider isn't in the LifeWise network, they may be able to continue treatment or specific covered services for a limited time with their existing provider.

Continuity of care: If a member is undergoing treatment, but their current provider is leaving the LifeWise network, they may be able to continue to receive treatment or care for specific covered services for up to 90 days with the existing provider.

Letter of agreement: A contract with an out-of-network facility or provider for specific services for a member. In-network benefits are provided for the services and the member isn't subject to balance billing.

Benefit-level exception: An exception made to allow in-network benefits for services provided at an out-of-network facility or by an out-of-network provider. The member is still subject to balance billing.

Ordering/servicing providers or facilities listed on the request (by NPI) can sign in to Availity to check request status through Availity's Auth/Referral Inquiry tool or dashboard. We typically respond to requests within 1-2 days, but it can take up to 3 days.

If the request is denied, we’ll mail a detailed letter to you and the member.

Carelon

For advanced imaging, prior authorization requests must go through Carelon Medical Benefits Management.

To request a prior authorization, register with Carelon and submit your request online or by phone at 866-666-0776. View our code list and the Carelon clinical appropriateness guidelines to assist you.

The following services are subject to review by Carelon:

• Genetic testing
• Imaging (CT scan, echocardiography, MRI, MRA, nuclear cardiology, PET scan)
• Radiation oncology
• Sleep study

The following services do not require prior authorization:

• Emergency room services
• Inpatient hospitalization
• Outpatient surgeries (hospitals and free-standing surgery centers)
• Observation stays

Servicing providers are strongly encouraged to verify that the prior authorization has been received before scheduling and performing services. In addition, imaging servicing providers must submit ordering/referring provider information, per guidelines from the Centers for Medicare and Medicaid Services (CMS), in boxes 17 and 17b on CMS-1500 forms.

eviCore

LifeWise group plans use eviCore healthcare for prior authorization for outpatient rehabilitation.

Check our code list to view outpatient rehabilitation codes. If no results are found, the code doesn't require review. Non-specific codes are reviewed when the claim is submitted.

To create an account and/or initiate an authorization:

• Visit eviCore healthcare
• Call 800-792-8751 from 7 a.m. to 7 p.m., Monday through Friday (Out-of-network providers: submit requests by calling this number.)
• Fax an eviCore healthcare request form to 800-540-2406
  (Go to Online Forms & Resources to select the specific treatment form.)

Trainings, clinical guidelines, performance summary reports, and more are available on the eviCore healthcare website.

Trying to see if a prescription medication requires prior authorization? Check out our formulary drug lists and drugs requiring approval web pages.

Visit our admission and discharge notification web page for information.

We know situations can happen that may make it impossible to get prior authorization before treating a patient, or to notify us within 24 hours of admission. If a patient’s emergency prevents you from getting prior authorization, you must notify us within 48 hours following onset of treatment, or as soon as is reasonably possible.

In these situations, contact us before submitting a claim. Follow the recommended practices outlined in the extenuating circumstances policy so that the claim isn't automatically denied.