Prior Authorization and Utilization Management

We are pleased to announce a new partnership with eQHealth Solutions to provide utilization management services effective Jan. 1, 2020.

US Health and Life requires prior authorization of certain services including:

• All inpatient admissions to any acute care facility require prior authorization and concurrent review.
• Certain outpatient surgeries, treatments, services, medications and durable medical equipment.

Providers must obtain prior authorization from eQHealth before the admission or services are provided. For a comprehensive list of procedures with the ICD-10 or CPT codes, please refer to the 2020 Services Requiring Prior Authorization List posted on the USHL website. If a request is submitted for services that do not require prior authorization, a response will be sent back to notify the requestor that prior authorization is not required for that service. Please check to ensure a service requires prior authorization before submitting a second request.

Please submit the following information when requesting prior authorization:

• 2020 Prior Authorization form
• Clinical documentation relevant to the request such as signs, symptoms, history, diagnostic tests results, consultant recommendations (if applicable) and plan of treatment.
• Anticipated length of stay

Download the Prior Authorization Request Form

Utilization management decisions are made in a timely manner to accommodate the clinical urgency of the request. eQHealth adheres to the timelines developed by URAC (Utilization Review Accreditation Commission and NCQA (National Committee on Quality Assurance) in responding to utilization management requests.

Processing times for prior authorization requests are based on the receipt of all required and relevant supporting documentation. Submitting requests without all relevant supporting documentation will result in longer processing times or the inability to process the request.

Prior authorization is not required for emergency or observation services, however, authorization is required within 2 business days from the inpatient facility if the member is admitted as a result of emergency or observation services.

For questions on how to submit a prior authorization request or to check the status of a request that has previously been submitted, please contact eQHealth customer service at (866) 356-3666.

For questions regarding benefits, eligibility and the list of services that require prior authorization, please call the customer service number located on the back of the member ID card.

Contact eQHealth

(866) 356-3666

Submit Prior Authorization by Fax: (586) 693-4829

Hours of operation are 8:00am to 8:00pm (ET) Monday to Friday, excluding holidays.

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