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.

Process:

  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 614-234-8672.
  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:


 

 

4-13-18
Oncology Prior Authorization Presentation

4-13-18 
Oncology Prior Authorization Webinar

 

 

 

 

 

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.


Updated 06/2018