Medicare Utilization Management Guidelines

Service Authorizations
A prior authorization request (PAR) must be submitted to AgeWell New York Utilization Management by phone, fax, or email per a member’s Plan benefits. The PAR form is available at www.agewellnewyork.com/for-providers/utilization-management-authorizations

All prior authorization requests (PAR) must be accompanied by clinical documentation supporting the request. AgeWell New York Utilization Management will attempt to obtain records no more than three times within 14 days for Standard Requests or within 72 hours for Expedited Requests. If a provider fails to send records after the three attempts the request for service will be denied.

  • If clinical documentation is not received within the 72 hours on an Expedited Request, it will be converted to a Standard Request which will allow additional time for clinical documentation to be submitted.

All Inpatient Hospital and Skilled Nursing Facility (SNF) admissions must be authorized by AgeWell New York Utilization Management. All services received during an admission are payable based on the authorization issued for the stay. Professional and ancillary claim payments are dependent on the admission authorization being obtained by the facility per UM Guidelines.

  • All facilities are required to notify AgeWell New York of a member’s Inpatient Hospital or SNF admission within 72 hours.
  • Concurrent reviews will be completed during which additional medical records will be required.

Should an authorization request be denied for lack of medical necessity, Providers have 48 hours from the determination to request a Peer-to-Peer review.

Plan Notification
Plan Notification may be made by any of the three following methods: 1. Phone, 2. Fax, 3. Letter. Notification of admission, intent, or need without a PAR is not a request for authorization.

Claims Appeals
Requests for authorizations submitted post-service are not applicable for Utilization Management review. All requests for reconsideration or authorization of services already rendered must be submitted as a Claim Appeal.

  • Timely filing for Medicare Claim Appeals is 60 days from the date of denial.

Once the authorization number is issued changes/adjustments/updates will only be made when reviewed and approved on Claim Appeal.

Authorization Request Form

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The approval of the services refers only to the medical appropriateness of the requested service(s) and does not represent guarantee of payment. Providers’ acceptance of an authorization to provide services constitutes agreement to accept payment in accordance with contract arrangements and CMS coverage and reimbursement rules. AgeWell New York’s reimbursement is payment in full, and Providers agree to look to the member/patient only for the applicable copayment, coinsurance, and/or deductibles. Additional services may require further authorization from AgeWell New York. Providers further agree to abide by AgeWell New York’s Claims, Quality, and Utilization Management policies currently in effect.