CA UR Timeframes
How long does the treating provider have to submit a voluntary appeal after a denial?
10 calendar days
When approving medications, what is the start date in the TP?
Date of office visit
When should OOT requests be completed by?
Within 5 days of the receipt date in the UR dept
When approving a stand alone request for labs, xrays, EKG or UA (non surgical), the end date in TP should reflect how many weeks?
4 weeks
Its Monday morning and you have 1 MCU, 1 Urgent and 1 day 5 on your board, what is the order in which you would ideally triage your board?
Day 5, MCU, Urgent
I received a retro request, when is the UR determination due?
Within 30 calendar days
When approving more than one medication BUT one has a refill, the end date in the TP should reflect what?
The longest prescription end date
I received a valid appeal request, when does this need to be addressed by?
Within 5 days of the Travelers receipt date
When approving an Ergo Eval and equipment, the end date in TP should reflect how many weeks?
4 weeks
No, the employer will perform eval/provide item
I received an urgent request, when is UR due?
Within 72hrs (no day 0)
When approving PT, acupuncture or psychotherapy treatment, how long is the authorization period?
Duration of time plus 8 weeks (ex. 3x2wks plus 8wks)
Upon reviewing a day 2 request, you determine additional information is needed to render a decision. You attempt to obtain the missing information from the provider, when will you set your diary for?
5th day in the UR process
When approving a stand alone request for follow up appointment, the end date in TP should reflect how many weeks?
4 weeks
What are the Smart UR (SUR) billing codes?
904a/904 and 905a/905
When is a UR determination due for MCU requests?
How many weeks are provided when a diagnostic, DME or injection is authorized?
8 weeks
I received a true appeal request. I can send this out to PA as a same day review. True or false?
False, DO NOT send appeal requests as a same day review unless the request is urgent.
When approving a stand alone request for consults or TOC, the end date in TP should reflect what?
One year from start date
What would you bill for combo approvals (regular and smart UR) completed on the same day ?
900a/900 or 901a/901 as these code trumps any SUR billing codes
When is a UR request due when seeking a negotiation of treatment?
How many weeks are provided when authorizing a surgical request?
12 weeks for approval date
You determine an OOT request needs to be sent to PA for further review. Can you send as a same day review?
No, do not send as a same day review as it is already OOT. Make the PA due date for when it makes sense for the claim.
What is the end date when a provider is requesting a 6-8 month authorization period for a surgical request?
No end date (no authorization dates)
What would you bill if you approve one or more SUR and sent the other requests to PA?
904a/904 or 905a/905 for the approved items using SUR, time spent on creating/sending the PA is rolled into the 'a' code.