What is a Care Request?

Care requests seek authorization from a health plan for drugs, services, and admissions. They can also contain requests for review, appeals, complaints, and grievances.

A care request includes member information, provider information, decision reason, and other information. A single request can contain multiple diagnoses, services, or drugs.

Consider this example:

A 75-year-old man with a history of varicose veins complains of pain in the leg when performing the daily exercise routine recommended by his primary doctor. He has failed a trial of medical-grade graduated compression stockings and requires minisurgical treatment for superficial varicose veins. This procedure is scheduled with a surgeon at an Ambulatory Surgical Center on 6/30/2018. The request is reviewed by a nurse for medical necessity, and the member and practitioners are notified when the requested service is approved.

In our example, the care request includes:

• A diagnosis: Varicose veins in the right leg.
• A service: Minisurgical phlebectomy at an ambulatory surgical center.