Referrals & Authorizations
Treatment Authorization
The treatment authorization form should be used when you are unable to access EpicLink and need to submit an authorization immediately.
IMPORTANT NOTE: if a member is missing from EpicLink, please fill out an online member add form located here. A member add form will be needed for authorization requests in EpicLink and requests using the Treatment Authorization form. If you have access to EpicLink, it is highly recommended that you fill out the member add form and, once the member has been added, use EpicLink to request the authorization.
If you need access to EpicLink, please request access here. Once your access has been provisioned, please use EpicLink for all authorization requests.
Please send to the appropriate number according to authorization priority.
- Routine/Standard Requests: 949-791-3491
- Urgent/Expedited Requests: 949-791-3492
- Inpatient Admission Notification: 949-791-3489
To find an In network HPP provider, please use: hoaghealth.org or click here for the HPP Provider Directory.
Frequently Asked Questions
Q: How long will it take for a determination to be made on a referral?
Q: In what instances would we use urgent as a priority?
A: Urgent should be used for medical necessity, not patient preference of a patient to get something approved quicker.
Q: How do we submit authorization request?
A: Preferred method – EpicLink, Fax – Complete the treatment authorization form and fax to the appropriate department.
Q: What is the quickest way to check the status of a referral?
A: You can check the status of a referral on EpicLink
Q: The doctor has not finished their note documentation. Do I need to wait for the clinical documentation before submitting a referral request?
A: You can submit the referral request without clinical documentation but we do not recommend it. If we do not receive proper clinical documentation, we will not be able to review the referral which may lead to a denial. We will call to obtain records if possible which will result in unnecessary burden on your office staff and delay a determination being made.
Q: The referral we submitted was denied but the doctor would like to discuss further. What steps do we take?
A: A peer to peer can be requested on any denial. The contact information for our MD reviewer will be on the letter generated to you or you may call us at 949-791-3502 to request.
Q: What criteria does UM to make a determination on a referral?
A: After determining eligibility and benefit coverage, UM makes determinations based on medical necessity. Listed below is the hierarchy that is used:
Medicare Advantage Plans:
- Plan Eligibility, Benefits and Coverage (Evidence of Coverage)
- Center for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs)
- Local Coverage Determinations (LCDs) or State Specific Mandates (Commercial)
- Local Coverage Medical Policy Articles (LCAs)
- Medicare Benefit/Coverage Policy Manual
- Medicare Claims Processing Manual
- Medicare Managed Care Manual
- Medicare Program Integrity Manual
- CMS Drug Compendia
- Health Plan Coverage Medical Polices (as applicable)
- Milliman Care Guidelines (MCG)
- National Comprehensive Cancer Network Guidelines (NCCN)
- Diagnostic and Statistical Manual of Mental Disorders (DSM V)
- American Society of Addiction Medicine (ASAM)
- Hayes Health Technology Website (https://www.hayesinc.com)
- RedBook/Micromedex
Commercial:
- Plan Eligibility, Benefits and Coverage (Evidence of Coverage)
- Health Plan Coverage Medical Polices (as applicable)
- Milliman Care Guidelines (MCG)
- National Comprehensive Cancer Network Guidelines (NCCN)
- Diagnostic and Statistical Manual of Mental Disorders (DSM V)
- American Society of Addiction Medicine (ASAM)
- Hayes Health Technology Website (https://www.hayesinc.com)
- RedBook/Micromedex
Authorization Approval Policies
A detailed breakdown of our policies is available on EpicLink.