Retrospective review is performed when a service has been provided, the claim has been submitted and no authorization had been given. Determinations for payment involving health care services that have been delivered will be made within 45 calendar days of receipt of necessary information.
All services are subject to retrospective review. Prior authorization or concurrent review decisions will not be reversed unless Prestige Health Choice receives information that contradicts the information given when the initial determination was made.
Criteria for Review Decisions
The Prestige Health Choice uses review criteria that is nationally recognized and based on sound scientific medical evidence to ensure consistent application of review criteria for authorization decisions. Prestige’s Quality and Performance Improvement Committee includes physicians with an unrestricted license in the state of Florida with professional knowledge and/or clinical expertise in the area who actively participate in the discussion, adoption and application of all utilization decision-making criteria on an annual basis.
Prestige Health Choice uses numerous sources of information including, but not limited to, the following criteria when making coverage determinations:
• medical necessity
• member benefits
• local and federal statutes and laws
• InterQual™
• Prestige’s Contract with AHCA
• Medicaid Coverage and Limitations Handbooks
The nurse reviewer and/or medical director apply medical necessity criteria in context with the member’s individual circumstance and capacity of the local provider delivery system. When the above criteria do not address the individual member’s needs or unique circumstance, the medical director will use clinical judgment in making the determination. Providers may request a copy of the criteria used for a specific determination of medical necessity.
