Member Requests 101
A request for a service or treatment that requires prior authorization.
What is a member request?
This type of request allows the member to see an OON provider using their INN benefits for this one situation.
What is a Gap Exception?
These types of OON facilities may have a red R in their profile or notes that they cannot be authorized to for a specific reason.
What are unavailable or restricted facilities?
For psychological testing, members are encouraged to receive ________ before making the request.
What is an initial assessment?
TAT is an acronymn for this.
What is turnaround time?
What is Transition of Care?
With a Gap Exception, if the provider is unwilling to agree to the terms of the contract with Optum, the member may be subject to, and responsible for, any _______ by the provider.
What is balance billing?
Authorization for HLOC is based on _________.
What is medical necessity?
There must be at least this many months between authorizations/notifications for testing.
What is 6 months?
When using the DARE Tool to determine TAT for commercial plans, Care Advocates quote this color TAT to the member.
What is white/determination TAT?
When a member/caller is calling to ask about and/or gain more information about a Gap Exception and/or a service requiring prior auth and they have not expressed a desire to request it.
What is an inquiry?
The difference between what a provider charges for services and what is reimbursed by the insurance company.
What is balance billing?
Without clinical information gathered from an initial assessment by the facility, the request may result in this.
What is a denial?
Though rare, another type of non-routine service that members may request include ________.
What is TMS?
When using the DARE Tool to determine TAT for Medicare plans, Care Advocates quote this color TAT to members.
What is green/Optum Goal?
Without __[this]__, callers cannot make a member request for anyone over the age of 18.
What is an AOR?
Gap Exceptions may be approved for lack of INN providers, continuity of care/clinical reasons, or this.
What is provider specialty?
For Medicare HLOC requests, the facility MUST have this.
What is a Medicare ID number?
In order to qualify for a TOC, members must be in ________ treatment with their provider.
What is active, continuous treatment?
There are 2 types of ASO plans to be mindful of when using the DARE Tool - ERISA and _______.
What is Non-ERISA?
All member requests follow UM processes and therefore, we must make a __________ on each request.
What is a determination?
As part of our Gap Exception process, our MRTs will submit a __________. This will be considered, in addition to clinical information, in the determination.
What is a CAST search?
What is OON/OOA exclusion/restriction?
Members whose providers are leaving the Optum network may be eligible for __[this]__.
What is Continuity of Care benefit?
When choosing 'Authorization Review Type' in the DARE Tool, always choose "Non-Urgent Pre-Service" for all LOC except this.
What is Inpatient (SUD/MH)?