Authorization Essentials
This describes the maximum period during which an authorized infusion service must be provided before a new authorization is required
what is the date range of the authorization?
This type of insurance, often offered to older adults and disabled individuals, consists of multiple parts, including A, B, C, and D, each covering different healthcare services.
What is Medicare?
This group of medications is used to treat severe infections?
What are IV antibiotics?
This happens when an insurance denies the authorization due to wanting the patient to go to a lower cost of care
What is a site of care denial?
This team member lives the furthest away
Who is Allyson?
This term describes when insurance companies review a request to determine if it meets medical necessity criteria
What is utilization review?
When an insurance company requires the patient to try a lower-cost medication before covering a more expensive one, this is called what?
What is step therapy?
This medication is used to treat moderate to severe asthma
What is Nucala?
In cases of some denials, healthcare providers often escalate the issue to this level, where a higher-level clinician or medical reviewer reassesses the case.
what is a peer to peer review?
This team member is one of the original 4 members of our team
Who is Dana?
In cases where the regular authorization process might delay necessary treatment, this type of authorization can be requested
What is an expedited or urgent request?
This government program, funded by federal and state governments, provides health coverage to eligible low-income individuals, families, and certain vulnerable populations
What is Medicaid?
This Medication is given in IV form to treat Osteoporosis
What is Reclast/ Zoledronic Acid?
This common issue arises when the insurer requires additional supporting information to assess the medical necessity of the requested treatment."
What is a request for additional documentation?
This team member is in the middle of a home remodel
Who is Christine?
This type of authorization is required when the service is requested after the patient has already received the infusion.
Under this provision, patients can continue their health insurance coverage after leaving an employer, though they often pay the full premium themselves.
What is Cobra?
This biologic medication is used to treat chronic inflammatory conditions like psoriasis and ulcerative colitis by targeting tumor necrosis factor
What is Remicade?
When a treatment or service is approved but only for a limited number of sessions or a shorter duration than requested, this is known as a ____________.
what is a partial or limited approval?
This team member is known for her artistic abilities
Who is Sonya
When the insurance denies authorization, this process allows for a review of the decision to try and overturn the denial
What is an appeal?
For Medicare beneficiaries, this type of plan, also known as Medicare Part C, combines hospital, medical, and often prescription drug coverage through private insurance companies
what is a Medicare Advantage Plan?
This type of infusion drug is commonly used to treat autoimmune diseases, such as rheumatoid arthritis and Crohn’s disease
what is a biologic?
We often have to ask for this when an insurance authorizes a max dose amount
what is an order cap?
This team member goes camping every year for her Birthday
Who is Jess?