Thank you for your patience during this time. Please submit online Inquiries to our Health Services and Prior Authorization team at MCHPHSRecords@mchs.com

As we navigate through the COVID-19 virus, our top priority is the health and welfare of our members. Our goal is to give members peace of mind and continue to support their health through innovative solutions, technology and personalized support.

Prior Authorizations

MediGold requires prior authorization on select services through our utilization management team. Please review the MediGold Prior Authorization List for codes requiring prior authorization.

 Essette Provider Authorization Portal

  1. Log on to the Essette Provider Portal to electronically submit an authorization request at https://provider.medigold.com/AuthPortal/Login.aspx
  2. Complete the prompts to document required clinical information.
  3. Upload clinical documentation and submit.  If all requirements are met, you will receive an automatic authorization approval. 
  4. If the request is pended for additional clinical review, MediGold will review the request by following our Prior Authorization Decision-Making Process. 
  5. You will receive a decision as expeditiously as the member's health condition requires.
  • Standard Request: Goal is three to five business days. Our average is 3.2 business days.

  • Expedited Request: A decision will be rendered within 72 hours of receipt.

 Process: Fax Requests

  1. Download a Prior Authorization Request Form from our website at MediGold.com/For-Providers/Tools-and-Resources/Forms.
  2. Complete the form with the required information and any additional documentation to support the request.
  3. Fax completed form to MediGold at 833-263-4869.
  4. MediGold will review the request by following our Prior Authorization Decision-Making Process.
  5. You will receive a decision as expeditiously as the member's health condition requires.

  • Standard Request: Goal is three to five business days. Our average is 3.2 business days.

  • Expedited Request: A decision will be rendered within 72 hours of receipt.

 Prior Authorization Decision-Making Process

Utilization review nurses determine medical necessity following the hierarchy of these guidelines:  

 

Oncology Required Documentation

Always required:Treatment requested (CPT/HCPCS code).

  • Diagnosis or clinical indication.
  • Clinical documentation to support medical need:
    • Eastern Cooperative Oncology Group Score (ECOG) or Karnofsky Performance Status (KPS).
    • Genetic findings or tumor markers.
    • Most recent lab results (bilirubin, PSA, CBC, CEA, AFP levels).
    • Prior imaging studies (CT, MRI/PET).
    • Office notes.

Additional medical oncology requirements:

  • Cycle start date, length and the number of cycles requested.
  • Medication doses per treatment.
  • Cancer stage/performance status.
  • Prior surgical intervention.

Additional therapeutic radiation therapy:

  • Type of radiation therapy.
  • Cancer staging.
  • Prior radiation treatment.
  • The number of fractions requested.
  • Dose per fraction.

4-13-18
Oncology Prior Authorization Presentation

4-13-18
Oncology Prior Authorization Webinar

Updated 02/2020