Utilization management describes proactive procedures such as; discharge planning, concurrent planning, precertification and clinical case appeals. It also covers proactive processes such as; concurrent clinical reviews and peer reviews, as well as appeals introduced by the provider, payer or patient.

The PCHP Utilization Management Program applies to all members for whom PCHP contracts to provide medical management services, including all members of Piedmont Community Health Plan and HealthCare.  Depending on the contract with an employer or third party, PCHP may be required to provide some or all of its utilization management services. The PCHP Utilization Management Program applies to services provided by in network and out of network practitioners and providers.

PCHP utilization management includes the following functions:

1. Out-patient care utilization management, including management of primary care and specialist practitioner services, out-patient diagnostic and surgical services, emergency services, durable medical equipment and specialty medication prescription management.
2. Out-patient Mental Health / Substance Abuse utilization management, including management of services by Mental Health / Substance Abuse practitioners and Mental Health / Substance Abuse diagnostic testing.
3. Pre-admission review and certification for non-urgent medical and Mental Hhealth / Substance Abuse admissions.
4. Admission review, concurrent hospital review/certification and discharge planning for medical and Mental Health / Substance Abuse hospital services.
5. Retrospective review of medical and Mental Health / Substance Abuse in patient, emergency and out patient services.

Piedmont Community Health Plan uses InterQual as the basis for determining medical necessity of medical and mental health/substance abuse care. PCHP recognizes that the InterQual serve as guidelines for care under routine circumstances and that in some instances, depending on the status of the member or the availability of medical or Mental Health / Substance Abuse services, these guidelines are not applicable.

In order for members to obtain the highest level of benefit coverage, PCHP requires that PCHP members use medical and Mental Health / Substance Abuse services by PCHP network practitioners and providers when the appropriate services are available and accessible. Referrals and requests for services outside the local PCHP network are reviewed by and authorized as appropriate by the Medical Director, Director of Medical Management or Psychiatric Medical Director.

The Piedmont Community Health Plan complaint and appeal system is to ensure that a fair an orderly process is available to covered members and to providers representing covered members in order to resolve disputes that are related to or arise out of contractual coverage with Piedmont Community Health Plan and Piedmont Community HealthCare. 

For more detailed information, please go to the link provided for the Piedmont Community Health Plan Utilization Management Policies and Procedures.

FORMS: Piedmont sometimes uses forms to assist with medical necessity decisions.

• 2024 Master Pre Authorization Codes - March Clarification
• 2024 Master Pre Authorization Codes - January Clarification
• 2024 Master Pre-Authorization Codes
• 2023 Master Pre-Authorization Codes - August Clarification
• 2023 Master Pre-Authorization Codes - July Clarification
• 2023 Master Pre-Authorization Codes
• Clinical Policies
• Clinical Policies can be found at this link. (For Provider Policies, e.g. Coding and Editing Policy, click here.)
• Drugs requiring NDC data with claims submission
• Medical Rebates Preferred Drug List July 2023 Commercial
• Medical Rebates Preferred Drug List July 2023 Exchange
• Preferred Drug List - April 2023
• COVID-19 Coding Guidelines

NOTE:  The preauthorization codes are a work in progress. This is not a complete list. Providers should contact Medical Management if you have questions about preauthorization necessity based on criteria.

As a valued Piedmont Provider, our goal is to assist you in serving our members.  To that end, participating providers can download printable Provider Forms by clicking on the following links: 

• Referral/Authorization Request
  Use this form to submit a request for a referral or authorization.

• Corrected Claim Request Form
  Use this form to submit a correction on a rejected claim.

• Appeal Request Form
  Use this form to submit a request to appeal a claim.

• DME Authorization Request Form
  Use this form to easily request authorization for DME.

• Network Participation Request Form (Organization)
  Please complete this form for your organization or practice to request to join Piedmont's provider network.

• Network Participation Request Form (Individual)
  Please complete this form for an individual provider to request to join Piedmont's provider network.  

• Network Participation Request Form (Individual Nurse Practioner)
  Please complete this form for a Nurse Practioner provider to request to join Piedmont's provider network. 

• Provider Information Update Form
  Existing Piedmont network providers, please use this form to submit updates to your information.

• Provider Manual  
  A provider's guide to resources, processes and information about working with Piedmont Community Health Plan.

• CPAP Authorization Request Guide 
  A one page infographic to summarize requirements for CPAP authorization requests.

• Security Standards
  Security standards as referenced from our portal “Information Access and Security Agreement."

Welcome to Piedmont Community Health Plan's provider log-in page. Here is where Piedmont network providers can access certain online services.

Online Registration - new providers need to establish a user name and password before they can login and access information. After that you will be able to:

• View Benefits
• Check Eligibility
• Check Claims
• Check Re-pricing Group List

Attention: Piedmont has a new Provider Portal, please click this link to Register as New User. Office Managers should request initial access as the Local Administrator, once access is approved you will have the ability to add access for your own staff.

CLICK HERE  for the step-by-step user guide for the new provider portal setup.

 CLICK HERE for first-time registration and for online account access.

 CLICK HERE to access to access 2021 EOP’s and Payment information (Note: This is site does not provide current eligibility as of 1/1/2022.).

  CLICK HERE  for the Network Participation Request form (Credentialing for physicians/practitioners).

 iExchange Provider Portal – New referral and pre-authorization portal (Effective 8-11-20)

 CLICK HERE To sign up to receive EFT only, or 835/EFT, from Piedmont Community Health Plan Inc. 

  CLICK HERE To sign-up to receive EFT from all payers processing payments on the ECHO platform, a fee for this service may be required.

Coming Soon.