Virginia Premier is committed to supporting providers by valuing the quality of care that our physicians and practitioners give to our members. Requests for authorization of member benefits are coordinated by the Utilization Management department. InterQual (IQ) criterion is used to make the determination of medical necessity for requested benefits.
How do I get more information?Providers may call 800-727-7536, press option 3 for Medical Management, then option 3 for Utilization Review
NPA List Search Tool
Click to download the NPA List General Rules or access the search tool.CompleteCare NPA General Rules (PDF)
UM Program Description
Effective 5/1/2015 Medical Management is Changing the Authorization Requirements for the Baby Care Program
We want to partner with our providers in an effort to streamline our authorization process for Case Management of the Baby Care Program and continue to provide quality care to our members.
Effective 5/1/15 we will require an authorization for code G9002 for Case Management services. For initial requests the provider should fax Virginia Premier Complete Care intake for referrals and authorizations at (877) 739-1364. To avoid any delay for our providers to complete an evaluation, G9001 will continue not to require an authorization prior to rendering the service. If the provider determines that Case Management services are indicated, they must submit a request with clinical documentation and completion of the Maternal High Risk Case Management Authorization (DMAS-50-M) or the Infant High Risk Case Management Authorization (DMAS-50-I). Clinical information will be reviewed by VPHP Case Managers and decisions will be based on medical necessity. Travel reimbursement billed with code S0215 does not require an authorization when billed in conjunction with an authorization for G9002.
We want to partner with our providers in an effort to streamline our authorization process for Home Health and Outpatient Therapies and continue to provide quality care to our members. This update will not impact the current process for our members who may qualify for Part C Early Intervention services.
For initial requests, the provider should contact Virginia Premier intake for referrals and authorizations. To avoid any delay for our providers to complete an evaluation and initiate treatments, the Referral Coordinator will approve the evaluation and two additional visits without clinical review. If the provider determines that additional visits are indicated, they must submit a request with clinical documentation. Clinical information will be reviewed by Medical Management, and additional visits will be approved based on medical necessity.