The NEMS MSO Utilization Management (UM) team reviews treatment authorization requests (TARs) submitted by providers. Services that require prior authorization varies between plans. TARs, and the supporting clinical documentation, may be submitted by fax or through the NEMS MSO Provider Portal (EZ-NET).
The UM team uses evidence-based clinical criteria and makes UM decisions timely. The turnaround time for decisions and notifications are as follows:
TAR | Receipt | Decision | Decision if Pend | Member Notification of Final Decision | Provider Notification of Final Decision |
---|---|---|---|---|---|
Routine | Day 0 | Within 5 business days from Day 0 | Up to 14 calendar days from Day 0 | In writing within 2 business days from the decision, but not to exceed 14 calendar days from Day 0 | Initially by telephone or fax and then in writing within 24 hours from the decision, but not to exceed 14 calendar days from Day 0 |
Urgent | Day 0 | 72 hours from Day 0 | 72 hours from Day 0 | In writing within 24 hours from the decision, but not to exceed 72 hours from Day 0 | Initially by telephone or fax and then in writing within 24 hours from the decision, but not to exceed 72 hours from Day 0 |
Concurrent (inpatient) | Day 0 | 72 hours from Day 0 | 72 hours from Day 0 | In writing within 24 hours from the decision, but not to exceed 72 hours from Day 0 (excluding approvals) | Initially by telephone or fax and then in writing within 24 hours from the decision, but not to exceed 72 hours from Day 0 |
Retrospective | Day 0 | 30 calendar days from Day 0 | N/A | In writing within 30 calendar days from Day 0 | In writing within 30 calendar days from Day 0 |
Authorization Required | No Authorization Required |
|
Authorization for the below services are not processed by NEMS MSOPlease contact the entities responsible for the following services:
|
Authorization Required | No Authorization Required |
|
Authorization for the below services are not processed by NEMS MSOPlease contact the entities responsible for the following services:
|
Important Notice:
- NEMS MSO reserves the right to review and modify authorization requirement based on established criteria and/or community standards of practice
- Payment is contingent upon eligibility at the time of service
- Provider is responsible for verifying member eligibility prior to rendering services