Virginia Premier Health Plan, Inc.

Utilization Management

You can click to view and print the PDFs from the following list. To save these PDFs, right click on the link and choose "Save Target As..."

No Prior Authorization List - General Rules

No Prior Authorization List Effective 040113- Printable

No Prior Authorization List  Updated 040113- Searchable
Search by entering the code or word into the find box in the adobe toolbar

Archived Listing of Searchable No Prior Authorization Lists

Primary Emergent Diagnosis Choose Not To Review List

Utilization Management Program Description

Utilization Review

How to read PDF files

In order to download and view PDF files, you should download the free Adobe Acrobat Reader and install it on your computer.

Part C Notice

Many practices caring for pediatric members with developmental delay diagnoses are familiar with Part C Early Intervention Services, known officially as Early Intervention Services for Infant and Toddler Connections of VA. This program encourages these pediatric members to be directed to DMAS certified providers of PT, OT and ST.

Qualifying children who are less than three years of age in need of PT, OT or ST services for developmental delay are guided to certified providers using the Central Point of Entry contact at (800) 234-1448. From here, the family and professionals work together to develop an Individualized Family Service Plan (IFSP). The IFSP is a plan of care for needed services.

Those children using the Central Point of Entry, who have completed an IFSP and accepted Part C Services, move directly to a certified provider. Should a family choose not to use the certified providers of Part C, the child may be referred to VPHP for authorization of medically necessary PT, OT or ST provided by a VPHP network provider.

Offices requesting services through VPHP, where the IFSP is not verified, will be contacted for redirection to the Central Point of Entry or to confirm that the family has opted to utilize VPHP network providers and not a Part C Provider.

Affirmative Statement About Incentives

Virginia Premier Health Plan, Inc. wants to assure its provider network and membership that all covered benefits are open to its members without regard to any financial gains from reduction in utilization.

Virginia Premier affirms the following regarding utilization management (UM) practices:

• UM decision-making is based only on appropriateness of care and services and the existence of coverage,
• Practitioners or other individuals are not rewarded for issuing denials of coverage or service of care, and
• UM decision makers do not receive financial incentives to encourage decisions that result in underutilization.

Please feel free to contact Virginia Premier's Medical Management or Compliance departments at (800) 727-7536 should you have questions regarding this practice.