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InterView Magazine

When a doctor writes a referral for a medical service it must be authorized by the doctor’s medical group. That means that th e need for the service meets the rules according to your Evidence of Coverage (EOC). Usually an authorization means you can receive the service and pay only a fraction of the cost, for example, a copay.


        We want to maximize your benefits bystretch ing the dollars available from Medicare. Therefore we try to make sure that you will receive your services from providers that we know and trust to give quality care and service and not overcharge.

  • We try to match the right provider to the right service. You wouldn’t want the orthopedic doctor performing your back surgery to be a hand specialist.
  • If you will need ongoing referral care we can track, anticipate and approve future services.

      Inter Valley works with a number of physician groups. Each group’s authorization process has some differences in the detail but overall they are very similar.

        Some services may not require any authorization. For example, most blood tests don’t require any thing except the doctor’s order for the test.

        Other services may be automatically approved. Your doctor needs to submit a request but receives approval before you leave the office. The process that comes to mind for many people is when the authorization needs to be reviewed prior to approval. Your doctor sends your clinical information to your doctor’s medical group where it is reviewed by knowledge able medical personnel. Over 90% of requests are approved. Only a physician can deny a request for authorization. The authorization decision is shared with the your doctor, you and the medical personnel who will be providing authorized services.



        Timely care is the first consideration. If you are having an emergency such as a heart attack don’t worry about an authorization, get emergency care an d the paperwork will get done later. A standard authorization decision may take up to 14 days. If you meet certain criteria (described in your EOC) you will get an expedited (also called a fast) decision. This type of decision can take no longer than 72 hours. Exceptions to these time frames and appeal options are described in your EOC.

        If you have any questions or concerns please call Member Services at 800-251-8191 or TTY/TDD 505-7108 for the hearing impaired. We want to help you get the medical services you need.

 


 

 

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