Medical Case Management staff will contact provider offices to schedule appointments for CMISP patients. A procedure authorization form containing an authorization number, a list of authorized services, and the period covered under the authorization will be mailed to the provider.
Providers should contact Medical Case Management for authorization if additional services are necessary or if services will be provided beyond the authorized period.
All non-emergent services require prior authorization by CMISP Medical Case Management Unit.
Request for Surgery:
If a provider is requesting authorization for surgery, a request should be sent to Medical Case Management with a copy of the physician's medical report, including test results. The letter should address the following:
Surgery - Type of surgery, extent and probable outcome.
Informed Consent - Patient has been informed and understands the surgery effects, etc.
The surgical request may be reviewed by the Unit's Medical Director prior to authorization. The surgery team consist of enrolled CMISP providers. Any applicable CMISP coverage is subject to CMISP maximum reimbursement guidelines.
Anesthesiologists and assistant surgeons should be sure to use the same codes that the surgeon uses to bill CMISP, with the appropriate service code modifier.
Physician History and Evaluation Reports - Consultation:
Physician History and Evaluation Reports are an important part of a Quality Case Management System, and are required to obtain authorization for payment of your services. Please return your reports within 2 weeks of date of service to Medical Case Management.
If you are requesting authorization for additional follow-up care, please include the reason, estimated time and CPT code of the requested service in your report. It will help us respond quickly to your request.
Claims submitted using a By Report code may be delayed since it will need to be reviewed by Medical Case Management and individually priced. When possible, use specific CPT codes to identify procedures. Reserve By Report codes for complex or unusual cases.
When a requested medical service is denied by Medical Case Management, the patient is informed of the appropriate due process available to him/her. A copy of the service denial notification is also sent to the requesting provider. If the patient chooses to appeal the service denial, he/she must request a review of that decision, in writing, within ten (10) WORKING DAYS of the date of the denial letter from Medical Case Management. The letter must state that he/she is requesting an appeal and why he/she is dissatisfied. The patient is encouraged to submit additional medical information to substantiate the medical reason for the requested medical service.