Terminology

Please note that we use the term “Prior Authorization” for all:

• Pre-certification (inpatient)
• Pre-authorization
• Prior approval
• Pre-determination

Prior Authorization Information

Disclaimer

Inpatient

The inpatient prior authorization process involves reviewing for future admissions, emergent admissions, and post-hospital admissions (such as long-term acute care (LTAC), skilled nursing facility (SNF), and inpatient rehab (IPR)). We perform evaluation for inpatient level of care as well as medical necessity utilizing InterQual® guidelines.

Depending on which store the policy holder works in, the inpatient reviewer will be either BlueAdvantage Administrators of Arkansas (BAAA) or a vendor, American Health Holding (AHH).

The Group No. on the front of the member ID card identifies which reviewer to send your request:

Group numbers

080464 – 080469, 080218, 080228, 080258, 080268, 080278, 080288

BlueAdvantage Administrators of Arkansas (BAAA):

For authorization, submit the request through the Availity portal or download the Prior Authorization request form.

Group numbers

080410 – 080415, 080458 - 080463

American Health Holding (AHH):

For authorization, please call AHH at 833-462-0104, fax to 877-665-5542, or download the Prior-Authorization Request form.

Outpatient

Outpatient prior authorization is a review prior to the time a specified outpatient procedure is scheduled. This review consists of checking clinical documentation to verify the medical necessity for the procedure and whether that service meets the criteria established under the health benefit plan (i.e., Walmart’s coverage policy). Outpatient services will also occasionally require utilizing InterQual® guidelines.

Depending on which store the policy holder works in, the outpatient reviewer will be either BlueAdvantage Administrators of Arkansas or a partner carrier, American Health Holding (AHH).

The Group No. on the front of the member ID card identifies which reviewer to send your request:

Group Numbers

080464 – 080469, 080218, 080228, 080258, 080268, 080278, 080288

BlueAdvantage Administrators of Arkansas (BAAA):

For authorization, submit the request through the Availity portal or download the Prior-Authorization Request form.

Group numbers

080410 – 080415, 080458 - 080463

American Health Holding (AHH):

For authorization, please call AHH at 833-462-0104, fax to 877-665-5542, or download the Prior-Authorization Request form.

Behavioral Health (BH)

Specific Behavioral Health (BH) services must have a prior authorization, including

1. Inpatient BH stays
2. Emergency BH admission (next business day)
3. Partial BH hospitalization program
4. Intensive BH outpatient program

BH authorizations are handled by partner carriers. Depending on which store the policy holder works in, the partner will be either Lucet or American Health Holding (AHH).

The Group No. on the front of the member ID card identifies which reviewer to send your request:

Group Numbers

080464 – 080469, 080218, 080228, 080258, 080268, 080278, 080288

Lucet

For authorization, please call Lucet at 877-891-9177 for assistance.

Group Numbers

080410 – 080415, 080458 - 080463

American Health Holding (AHH):

For authorization, please call AHH at 833-462-0104, fax to 877-665-5542, or download the Prior-Authorization Request form.

High Tech Radiology (HTR)

Specific High Tech Radiology (HTR) procedures including MRIs, CTs, PET scans, and nuclear cardiology, must have prior authorization.

HTR authorizations are handled by partner carriers. Depending on which store the policy holder works for, the partner will be either Carelon or HealthHelp.

The Group No. on the front of the member ID card identifies which reviewer to send your request:

Group Numbers:

080464 – 080469, 080218, 080228, 080258, 080268, 080278, 080288

Carelon:

For authorization, call 866-688-1449.

Group Numbers:

080410 – 080415, 080458 - 080463

HealthHelp:

For authorization, you may utilize HealthHelp’s provider portal, which is available 24 hours a day, 7 days a week (including holidays). You may contact HealthHelp by phone at 877-492-0525 Monday through Friday from 8am to 6pm EST.

Specialty Medications

A prior authorization is required for specialty medications. OptumRx will work with you to make sure the medication is clinically necessary for your patient’s treatment. If you have questions concerning specialty medications, call OptumRx at 844-705-7493.

Pre-notification

The process of pre-notification is the receiving of information from health care providers before a member undergoes a course of care such as dialysis. Please call the number on the back of the member’s Plan ID card for more information.