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Provider Manual

Utilization Management

Last Updated on August 28, 2018

NOTICE: Imaging, radiation oncology prior authorizations expand

The prior authorization requirements for high-end imaging and radiation oncology have expanded for 2016 to include all Security Health Plan health plan types including commercial and BadgerCare as well as Medicare Advantage. Click here for details.

General Information

General information regarding UM processes

General Information

Prior Authorization/Notification

Services that require prior authorization or notification.

Prior Authorization

eviCore

High-end imaging services that require prior authorization from eviCore:

  • CT
  • CTA
  • MRI
  • MRA
  • PET

New: Effective 2/1/2016, radiation oncology services will require prior authorization from eviCore. For a list of services and CPT codes needing prior auth click on the Radiation Services button below.

eviCore

Radiation Services

naviHealth

  • Services for skilled nursing services that require prior authorization from naviHealth:
  • Acute rehab admission
  • LTAC admission
  • Skilled nursing facility admission

NaviHealth

Northwood

DMEPOS services that require prior authorization from Northwood

Northwood

Utilization Management Policies and Procedures

Established policies & procedures that govern our UM program.

Utilization Management Policies