Welcome

We look forward to serving you. We want your experience with us to be great. We promise to serve and care for you in the same way we would want our family to be treated.

Utilization Management

Ultimate Health Plans (UHP) has a department that implements and maintains Utilization Management (UM). The role of that department is to provide appropriate and quality care to our members. The UM department receives and reviews prior authorization requests, including inpatient and outpatient services and treatments. Additionally, the department performs concurrent reviews, participates in discharge planning and collaborates with the case management and provider relations teams.

UM Decisions

The UM department receives requests from members, providers, member representatives and specialists to review requests for services and/or treatments for members. The department uses the following criteria to make medical necessity decisions:

  • National Coverage Determinations (NCD)
  • Local Coverage Determinations (LCD)
  • Coverage Issues Manual (CIM)
  • Member’s Benefit Coverage (as described in the Evidence of Coverage)
  • Regulatory and or governmental bodies (FDA, NIH, Etc.)
  • Federal or State Mandates
  • InterQual Criteria
  • Medical Specialty Organizational Guidelines (ACC, ACR, AGOG, Etc.)

The UM department bases its decisions on the appropriateness of care, including the existence of coverage. For a copy of the UM Review Criteria, please contact the UM Department at 888-657-4170 (TTY 711).

Prior Authorization Form

Some services are covered by our plan only if your Primary Care Physician (PCP) or other provider gets permission from Ultimate Health Plans first. This is called a Prior Authorization.

Authorization Process Overview
English - Updated 1/18/2021

Prior Authorization Exclusion List

A list of our services that do not require prior authorization.
English - Updated 01/01/2023

Prior Authorization Form

Request prior authorization for medical services and procedures requiring it by having your provider complete the form.

English - Updated 7/11/2019

Timeframes for Prior Authorization Review

Ultimate Health Plans processes authorization requests according to the following general time frames, which comply with Medicare guidelines:

  • Standard- decision within 14 calendar days from the date of request.
  • Expedited- decision within 72 hours from the date of the request (including weekends and holidays). Conditions meeting criteria for expedited review include an imminent or serious threat to the health of the Member, including, but not limited to, severe pain, potential loss of life, limb or major bodily function. Please, only submit authorizations for expedited review if you can support that the above criteria applies to your request.
  • Standard Part B Medication- decision within 72 hours from the date of request.
  • Expedited Part B Medication- decision within 24 hours from the date of the request (including weekends and holidays). Conditions meeting criteria for expedited review include an imminent or serious threat to the health of the Member, including, but not limited to, severe pain, potential loss of life, limb or major bodily function. Please, only submit authorizations for expedited review if you can support that the above criteria applies to your request.

NOTE: Please ensure that your authorization request includes adequate documentation and/or information to medically support the request. If the information submitted is not adequate, the determination will be based upon the available information and/or lack of medical information. To expedite the process and to ensure appropriateness of the decision, it is very important that relevant clinical information be submitted with the request.

Request for Extensions: Ultimate may extend the decision time frame up to 14 calendar days. This extension is allowed if the enrollee requests the extension or if the provider or Ultimate can justify a need for additional information and documents how the delay is in the best interest of the enrollee.