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.

Utilize GAMMIS Centralized Web Portal for the following requests:

• Inpatient Hospital Admissions and Outpatient Hospital or Ambulatory Surgical Center Procedures
• Durable Medical Equipment
• Children’s Intervention Services
• Newborn Deliveries
• Hearing aid services
• Orthotics and Prosthetics
• Outpatient Behavioral Health Services (excluding Psychological Testing, Intensive Outpatient Program (IOP) and Partial Hospitalization Program (PHP).

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: Evolent
• Chemotherapy and Radiation Cancer treatments:Evolent (New Century Health), or by phone at 888-999-7713.
• Dental: Envolve Dental 1-844-464-5632
• Vision: Envolve Vision 1-800-531-2818 (Routine vision checks, glasses and contacts)

Forms/Resources

• Inpatient Prior Authorization Fax Form (PDF)
• Outpatient Prior Authorization Fax Form (PDF)
• Outpatient Prior Authorization Supplemental Fax Form (PDF)
• Outpatient Treatment Request Form Tips (PDF)
• Prior Authorization Guidelines (PDF)

AFFIRMATIVE STATEMENT

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