The Daily Dose
CDPHP Introduces Prior Authorization for High-Tech Radiology Services to Ensure Quality Care
At CDPHP, we are committed to maintaining high-quality, cost-effective health care for our members. As part of our ongoing efforts, we are introducing prior authorizations for high-tech radiology services—specifically MR, CT, and PET imaging. This initiative, affecting all lines of business, aims to ensure members receive appropriate tests at the right time and place.
Due to a regulatory approval delay, we are temporarily postponing the planned date (September 9, 2024) when these prior authorizations were to go into effect. A new effective date will be announced soon.
An Important Change for Improved Outcomes
Our comprehensive review of the health plan market highlighted a concerning trend: a significant increase in unnecessary high-tech radiology tests and treatments. By implementing prior authorizations, we aim to:
- Reduce Overutilization: Proper management is expected to lower medical spend while ensuring accurate care.
- Enhance Care Quality: Ensuring tests are necessary improves quality and patient safety.
- Align with Industry Standards: Unlike most health plans, CDPHP has not required prior authorizations for these services. This change aligns us with industry practices.
HealthHelp: The Right Partner for the Best Decisions
To facilitate this new process, we are teaming up with HealthHelp, a leader in specialty benefits management. HealthHelp will manage the approval process using evidence-based guidelines from the American College of Radiology, the Centers for Medicare & Medicaid Services (CMS), and other medical specialty societies.
Their innovative approach focuses on:
- Evidence-based decisions
- Provider support and education
- Expedited responses when a time-sensitive review is needed and immediate approvals for routine clinical scenarios that meet certain criteria
Their program is centered on achieving the best possible patient outcomes, which is achieved through collaborative discussions with providers. This results in a low denial percentage and mitigates provider and member abrasion.
20+ years of experience in clinical and care management
Academically affiliated with 30+ leading academic medical schools
Complete with Clinical Experts
- Physician Advisory Committee
- 150+MDs across multiple specialties
- 450+Nurses across global locations
Q. Will this prior authorization result in scheduling delays?
Timely care is crucial. The new system with HealthHelp is designed to minimize delays:
- Automatic Approvals: Many requests meeting evidence-based criteria will be instantly approved.
- Regulatory Turnaround Times: Compliance with federal guidelines ensures prompt processing:
- Commercial: Decisions within three business days (up to 45 days if additional information is needed).
- Medicare: Determinations within 14 days.
- Urgent Requests: Prior authorization within 72 hours across all lines of business.
Q. What if the service isn’t approved? How will the member be notified?
In cases where services do not meet clinical criteria, CDPHP and HealthHelp work collaboratively with providers to find suitable alternatives.
Both the member and provider will receive written and verbal notifications, including information on appeal rights.
More Information
- For details about the request process, provider training webinars, FAQs, and more: www.HealthHelp.com/CDPHP
- For updated policies and to access the HealthHelp approval system, log in to your account at provider.cdphp.com
Alexa Kerins About the Author
Alexa is a senior communications consultant at CDPHP who plans, writes, and edits communications for a variety of projects. She is an eternal optimist who likes good food, fun exercise classes, traveling, and spending quality time with her family and friends. You can often find her obsessing over her mini golden doodle and uttering cheesy quotes like “you’re the bee’s knees” and “team work makes the dream work."
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