Utilization Management

Peach State’s Utilization Management Department hours of operation are Monday through Friday (excluding holidays) from 8 a.m. to 5:30 p.m. Urgent Requests and Admission Notifications should call 1-800-704-1484 and follow prompts.

  • To notify the plan of inpatient hospital admissions and observations by the next business day of admission. A telephone authorization must be followed by a fax submission of clinical information by next business day.
  • You may also call to request outpatient authorizations for urgent and time sensitive services when warranted by the patient’s condition. Please include CPT and ICD-9 codes and place of service codes with your authorization request.

For authorization requirements for the following services, please contact the vendors listed below.

  • Hitech imaging such as: CT, MRI , PET and all other imaging services: National Imaging Association (NIA) - http://www.radmd.com
  • Chemotherapy and Radiation Cancer treatments: eviti - eviti.com

For authorizations related to home health, home infusion, durable medical equipment and supplies, call Peach State Health Plan at: 1-800-704-1483.

Forms/Resources

Inpatient Prior Authorization Fax Form

Outpatient Prior Authorization Fax Form

Prior Authorization Guidelines

Peach State Health Plan does not reward or pay its group of providers, or employees for completing medical use reviews. They do not pay its group of providers or employees to deny reviews. Use decisions are based on the following reasons:

  • Services are medically needed
  • Services are covered in the member’s plan

Our systems allow us and our partners to:

  • Identify
  • Track
  • And monitor the care given

This process ensures that you (member) receive the right healthcare.

We care about your health and want you to get better. We use certain methods to make sure that you receive the best healthcare for your condition. Those processes are listed below:

  • Watch for under and over use of services – best course of action is taken if this occurs
  • A system in place to support the study of medical use measurements
  • Detect possible quality of care issues
  • Put into action intervention plans
  • And measures the success of the actions taken
  • A process to support stability of care across the health care field