Molinalogo

We use evidence-based clinical practice guidelines when making decision about members’ care.

Clinical practice guidelines address preventive, acute or chronic and behavioral health services. These guidelines are reviewed at least every two years and updated as necessary. When this happens, we notify all network practitioners.

When determining the medical appropriateness of a service, we apply these criteria while considering individual circumstances and the local delivery system.

Clinical and UM staff make decisions based solely on appropriateness of care and existence of coverage. We do not reward staff for issuing denials of coverage. We do not encourage under utilization by providing financial incentives to deny coverage.

View our Clinical Practice Guidelines

The Health Care services (HCS) department conducts concurrent review on inpatient cases and processes prior authorizations/service requests. The HCS department also performs care management for Members who will benefit from care management services. Participating Providers are required to interact with Senior Whole Health’s HCS department electronically whenever possible. Prior authorizations/service requests and status checks can be easily managed electronically. For additional information please refer to the Health Care Services section of this Provider Manual.

Managing prior authorizations/service requests electronically provides many benefits to Providers, such as:

• Easy to access 24/7 online submission and status checks

• Ensures HIPAA compliance

• Ability to receive real-time authorization status

• Ability to upload medical records

• Increased efficiencies through reduced telephonic interactions

• Reduces costs associated with fax and telephonic interactions

Senior Whole Health offers the following electronic prior authorizations/service requests submission options:

• Submit requests directly to Senior Whole Health via the Availity portal

• Submit requests via 278 transactions. See the EDI transaction section of Senior Whole Health’s website for guidance

Prior Authorization Fax:

• Advanced imaging: (877) 731-7218

• D-SNP Outpatient Requests: (844) 251-1450

• All Other Products Outpatient Requests: (844) 251-1451

• Hospital inpatient and concurrent review requests: (844) 834-2152

• Medicare transplants: (877) 813-1206

• Post Acute Admission (skilled nursing facility (SNF), LTAC (LTAC), and acute inpatient rehabilitation (AIR): (833) 912-4454

If members receive care from out-of-network providers without prior authorization, SWH will not pay for this care. PCPs should contact us if they wish to request an exception referral for the member to see an out-of-network provider. If an out-of-network provider gives an SWH member emergency care, the service will be paid.

Visit our Forms page when submitting prior authorization and utilize the PA Look Up tool to determine if authorization is required. Refer to the provider manual for more information about prior authorization.

The Integrated Care Management (ICM) Program provides care coordination and health education for disease management, as well as identifies and addresses psychosocial barriers to accessing care with the goal of promoting high quality care that aligns with a Member’s individual health care goals. Care Management focuses on the delivery of quality, cost-effective, and appropriate health care services for Members. Members may receive health risk assessments that help identify physical health, behavioral health, medication management problems, and social determinants of health to target high-needs Members who would benefit from more intensive support and education from a case manager. Additionally, functional, social support and health literacy deficits are assessed, as well as safety concerns and caregiver needs.

1. 1. The role of the Case Manager includes:
• Coordination of quality and cost-effective services.
• Appropriate application of benefits.
• Promotion of early, intensive interventions in the least restrictive setting of the Member’s choice.
• Assistance with transitions between care settings and/or Providers.
• Provision of accurate and up-to-date information to Providers regarding completed health assessments and care plans.
• Creation of ICPs, updated as the Member’s conditions, needs and/or health status change.
• Facilitation of Interdisciplinary Care Team (ICT) meetings as needed.
• Promote utilization of multidisciplinary clinical, behavioral and rehabilitative services.
• Referral to and coordination of appropriate resources and support services, including but not limited to Long-Term Services & Supports (LTSS).
• Attention to Member preference and satisfaction.
• Attention to the handling of Protected Health Information (PHI) and maintaining confidentiality.
• Provision of ongoing analysis and evaluation of the Member’s progress towards ICP adherence.
• Protection of Member rights.
• Promotion of Member responsibility and self-management.
2. 2. Referral to Care Management may also be made by the following entities:
• Member or Member’s designated representative(s)
• Member’s Primary Care Provider
• Specialists
• Hospital Staff
• Home Health Staff
• SWH staff
  
  Care Management email: Medicare_CM_Team@MolinaHealthcare.com

SWH Member Services is available to help our members if they have any questions about their benefits and services.

• Member services staff are available Monday through Friday from 8 a.m. to 8 p.m. local time. Members can leave a voice message during non-business hours. We suggest our members leave a voice message with their question if it can wait until the next business day.
• SWH offers free interpreter services to our members. As a provider, you are required to identify the need for interpreter services for your patients who are SWH members and offer them appropriate assistance.