Prior Authorizations
What is an authorization?
A decision by a health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary.
After receiving services from a Provider, the Provider has how many days to submit a claim to UHC for payment?
180 days
What is the difference between an appeal and a grievance?
Grievance- a complaint or objection regarding the coverage, operations or management policies of the health plan.
Appeal- a dispute over a determination made by the health plan to deny, suspend, reduce, or change a service because we have determined the service is not medically necessary.
What is a Pharmacy Lock?
Program designed to protect the member's health and safety. It encourages members to use their pharmacy benefit in a healthier way and to prevent a potentially dangerous situation (unwanted side effects, interactions, etc.).
What does SDOH stand for?
Social Determinants of Health
Social factors that affect a member's health either directly or indirectly; i.e. housing, food, clothing, etc.
What is the TAT for a standard authorization once received by UHC?
OH- 10 Calendar Days
NY- 3 Business Days
PA- 2 Business Days
We are unable to answer any questions regarding claims while they are processing. How long do claims take to finish processing?
30-45 days
What system do we use to view Appeals and Grievances that have already been submitted?
Appeals Tracking System (ATS)
What is Step Therapy?
Step therapy is trying other medications first before stepping up to medications that cost more. It allows us to validate less expensive medication options do not work before a member's plan will cover the more expensive medication.
Where do you find authorizations for Vision and Dental Services?
UHC Dental - For Dental
March Vision - For Vision
You would need to call these departments.
How can you identify if the member received a Bill or an EOB?
Ask member if statement says "This Is Not a Bill."
Ask member if the statement came from UHC or the provider.
What does it mean to expedite an appeal?
The caller requests a faster response when processing their appeal.
Which intent can be utilized to assist a member calling in with issues filling a prescription?
Ex. A rejected RX
Pharmacy Claims Intent
If the 'Member Refused' option is selected on a member's SDOH NBA, how long will the NBA be removed from the account?
12 months
Where would you find a decision on a medical authorization? (Be Specific with the steps)
Authorizations/Referrals Intent in Maestro
AND/OR
ICUE-->Search Member-->History Tab-->Locate the authorization-->Decisions Tab
If member received a bill from a provider and claim was rejected due to no authorization being on file. Can the provider submit an authorization now to have the service covered?
NO. An authorization will NOT be approved after the service has already been provided. Provider will need to write off the amount and cease billing the member.
If a caller does not agree with an appeal decision what is their next step in the appeal process?
NY & PA- Fair Hearing
OH- State Hearing
Which intent would you use to assist the member with locating their BIN/PCN/Group # for prescription coverage?
Pharmacy Benefits Intent
What is an SDOH NBA?
SDOH Next Best Action- NBA is a service alert advising the member needs to be screened for SDOH needs and possible community resources.
After advising a member that an authorization was denied, what option does the member and their provider have before appeal?
A Peer to Peer request
Provider can request at 800.955.7615
If a Provider refuses to cease billing a member, what is your next step?
To file a Billing Grievance via Maestro
How long after receiving the Notice of Action (NOA) does a member have to file an appeal?
60 days
If a member calls in the check the status of a Prescription Authorization, where would that be located?
RX Claims
What information needs to be included in the documentation when SDOH resources are located for a member?
1) Name of the resource
2) Phone Number
3) Address