Prior Authorization Form/Instructions
University Health Care - Healthy Advantage (HMO) Contact Information:
| PHONE: | (866) 472-9479 | |
| Monday through Friday, 8:00 a.m. - 5:00 p.m. | ||
| FAX: | (866) 472-9481 | |
| MAIL: | University Health Care - Healthy Advantage (HMO) | |
| Attention: Authorizations | ||
| 7050 South Union Park Center Suite 200 | ||
| Midvale, Utah 84047 |
Required Information:
- Complete member, provider and service information as found on the
Prior Authorization Form - Current (up to 6 months), adequate patient history related to requested service
- Relevant physical exam
- Relevant specialty consultation notes
- Relevant laboratory and imaging results (including results of previous x-rays, CT scans, MRI scans, etc.)
Processing and Notification:
- University Health Care - Healthy Advantage (HMO) will process any Standard "non-urgent" requests as quickly as required by the member's condition but no later than 14 calendar days of receipt of a request. Expedited "urgent" requests will be processed as soon as possible but no later than 72 hours of receipt of the request.
- Upon approval the requestor will receive an authorization tracking number.
- If a request for services is denied, the requesting provider and the member will receive a letter explaining the reason for the denial and additional information regarding the grievance and appeals process. Denials also are communicated to the provider by telephone or fax. Verbal and fax denials are given within one business day of making the denial decision, or sooner if required by the member's condition. Providers can request a copy of the criteria used to review requests for medical services or discuss the case with a University Health Care - Healthy Advantage (HMO) physician reviewer by contacting the UM department at 1-866-472-9479.
***Referrals to Network Specialists do not require Prior Authorization***
Those procedures that are not a Medicare covered benefit may be covered under the member's Medicaid benefit. Because Federal regulations and Medicare coverage
determinations are subject to change, the authorization guideline document is also subject to change and may not include all services that require prior authorization.
If there are questions regarding the need for prior authorization it is strongly recommended that the service provider contact University Health Care - Healthy Advantage (HMO) Plan.
The clinical criteria used to make UM decisions is available for your review
by calling Healthy Advantage (HMO) at 1-866-472-9479, Monday through Friday,
8:00 a.m. - 5:00 p.m.
Elective Admissions require prior authorization. All emergent admissions require notification within 24 hours of admission or next business day.
If there are questions regarding the need for prior authorization it is strongly recommended that the service provider contact University Health Care - Healthy Advantage (HMO) Plan.
The clinical criteria used to make UM decisions is available for your review
by calling Healthy Advantage (HMO) at 1-866-472-9479, Monday through Friday,
8:00 a.m. - 5:00 p.m.
Elective Admissions require prior authorization. All emergent admissions require notification within 24 hours of admission or next business day.