Certain items and services require prior authorization (pre-certification) to evaluate medical necessity and eligibility for coverage. See the current Authorization List to determine if prior authorization is required for general categories of services.

We use both internal and external resources in the authorization process. For the services listed below, the process is handled by the organizations indicated.

Clinical Review Criteria - Effective July 20, 2023, Health First Health Plans will begin utilizing internal Medical Policies for medical service prior authorization reviews. Health First Health Plans will follow the Coverage Determination Process as outlined below. Benefits are ultimately controlled by provisions contained in plan documents, which may include limitations and exclusions. In the event of a conflict between plan documents and coverage guidelines, plan documents will prevail. For Health First Medicare Advantage Plan members, plan documents will include, at a minimum, services covered by Original Medicare.

Coverage Determination Process - Health First considers multiple factors when making coverage determinations, including member benefit contracts, applicable laws and regulations, and the medical necessity of a requested item or service in context of a member's unique clinical situation. The following evidence-based resources will be applied by appropriate reviewers:

• Internal evidence-based Medical Policies
• The Centers for Medicare & Medicaid Services (CMS) coverage guidelines including but not limited to National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and Medicare manuals. If applicable guidelines exist, they must be used for Medicare members.
• MCG Guidelines (formally known as Milliman Care Guidelines).  Check the guidelines here. 
• Hayes Reports including but not limited to Health Technology Assessments, Medical Code Briefs, and Precision Medicine Assessments.
• Up-To-Date Clinical Decision Support.
• Peer-reviewed published medical literature.
• Clinical guidelines from nationally recognized authorities such as NCCN.
• FDA approval status (approval does not imply medical necessity).
• Other information deemed reliable and relevant by clinical reviewers.

Health First delegates utilization management of certain services, including behavioral health and substance abuse services. These third-party delegates develop and adopt their own clinical criteria.

Health First evaluates and adopts the above-mentioned guidelines (including delegate guidelines) at least annually.

If you have questions about an existing guideline, would like to request a copy of guideline used for a prior auth decision, or would like to request an assessment of new technology for coverage, please e-mail our Utilization Review Team at HFHPClinicalServices@hf.org.

Behavioral Health - For services in 2022: Small and Large Group commercial plans will continue to utilize Magellan Healthcare for behavioral health needs. For Medicare and Individual plans, behavioral health needs will be managed by Optum. Please visit the following sites for any authorization related needs through Optum: Individual plans Medicare plans. For services in 2023: All plans managed by Health First Health Plans will utilize Optum for behavioral health needs. Optum can be reached at 1.877.890.6970 (Medicare) or 1.866.323.4077 (Individual & Family Plans) or online: Individual plans Medicare plans.

All Other Authorization Requests – We encourage participating providers to submit authorization requests through the online provider portal. Multiple enhancements have been made to the Provider Portal, including the ability to receive "real-time" authorizations if certain criteria are met. Non-participating providers are encouraged to submit authorization requests via fax to 1.855.328.0059.