Utilization Management

    HAP CareSource™ MI Health Link (Medicare-Medicaid Plan) is committed to maintaining the quality and appropriateness of health care services provided to our members. The Utilization Management (UM) department performs all UM activities including prior authorization, concurrent review, discharge planning and other activities. HAP CareSource MI Health Link makes its UM criteria available free of charge in writing by mail, fax, phone or email and on this webpage.

    Mail:    CareSource
                P.O. Box 1307
                Dayton, OH 45401-1307

    Fax: 844-633-0399

    On an annual basis, HAP CareSource MI Health Link completes an assessment of satisfaction with the UM process and identifies any areas for improvement opportunities.

    Prior Authorization

    HAP CareSource MI Health Link understands that you may have questions about prior authorization. Access the Prior Authorization webpage for detailed information.

    Medical Necessity Criteria

    HAP CareSource MI Health Link utilizes nationally recognized criteria to determine medical necessity and appropriateness of inpatient hospital, rehabilitation and skilled nursing facility admissions. These criteria are designed to assist health care partners in identifying the most efficient quality care practices in use today. They are not intended to serve as a set of rules or as a replacement for a physician’s medical judgment about individual patients. HAP CareSource MI Health Link defaults to all applicable state and federal guidelines regarding criteria for authorization of covered services. HAP CareSource MI Health Link also has policies developed to supplement nationally recognized criteria. If a patient’s clinical information does not meet the criteria, the case is forwarded to a HAP CareSource MI Health Link Medical Director for further review and determination. Physician reviewers from HAP CareSource MI Health Link are available to discuss individual cases with attending physicians upon request.

    Utilization review determinations are based only on appropriateness of care and service and existence of coverage. HAP CareSource MI Health Link does not reward health care partners or our own staff for denying coverage or services. There are no financial incentives for our staff members that encourage them to make decisions that result in underutilization.

    Our members’ health is always our number one priority. Upon request, HAP CareSource MI Health Link will provide the clinical rationale or criteria used in making medical necessity determinations. You may request the information at no cost to you by calling or faxing the HAP CareSource MI Health Link Utilization Management department. You can reach us by phone at 1-833-230-2159.

    Access to Staff

    Providers may call our toll-free number at 1-833-230-2159 to contact Utilization Medical Management staff with any UM questions.

    • Medical necessity determination requests can be submitted 24 hours a day, seven days a week via a dedicated fax line and the HAP CareSource Provider Portal.
    • Staff members are available from 8 a.m. to 6 p.m. Eastern Time (ET) Monday through Friday for inbound calls regarding UM issues.
    • Staff members can receive inbound communication regarding UM issues after normal business hours.
    • Providers may leave voice mail messages on these telephone lines after business hours, 24 hours a day, seven days a week.
    • Staff members can send outbound communication regarding UM inquiries during normal business hours, unless otherwise agreed upon.
    • Staff members are identified by name, title and organization name when initiating or returning calls regarding UM issues.
    • Staff members are available to accept collect calls regarding UM issues.
    • Staff members are accessible to callers who have questions about the UM process.

    In the best interest of our members and to promote their positive health care outcomes, HAP CareSource MI Health Link supports and encourages continuity of care and coordination of care between medical health care partners as well as between behavioral health care partners.

    Member Support Services

    Representatives are available to answer member questions regarding UM.

      • Representatives are available by telephone Monday through Friday, except on the following holidays: New Year’s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day
      • Members may access Member Services by calling our toll-free number, 1-833-230-2057 (TTY for the hearing impaired: 1-833-711-4711), 8 a.m. – 8 p.m. Eastern Time (ET), Monday through Friday, and following the menu prompts.
    • HAP CareSource MI Health Link offers language interpreters for members who need assistance to communicate with HAP CareSource MI Health Link to discuss UM issues. These services are available at no cost to the member. As a provider, you are required to identify the need for interpreter services for your HAP CareSource MI Health Link patients and offer assistance to them appropriately.