Auth Rules
True or False: We can extend the date range on a partially approved authorization.
False. Date ranges on partial approvals cannot be extended; use P2P or appeal for more coverage.
What steps should you follow when modifying an authorization with a pending status?
Create a task, enter notes, and advise provider to submit clinical documentation.
What’s the first step in building rapport with a caller?
Greet them warmly and use their name.
To verify a provider requesting PHI, name one valid pair of identifiers.
(1) Provider/Facility Name + Tax ID, or (2) Provider/Facility Name + NPI.
What three things a provider can check via the portal?
Auth Status, eligibility and whether or not an auth is required.
What two options should a provider consider if additional units or dates are needed after a partial approval or denial?
P2P within TAT or file an appeal per plan rules.
If a provider asks to modify a determined authorization, what’s one step you must take if it’s expired or they want more units?
Advise them to submit a new request.
What should you do if you need to place a caller on hold?
Ask permission, explain why, and check in if it takes longer.
True or False: It’s okay to disclose an auth number before verifying the caller.
False. Verify first, then disclose.
What should you do if an authorization contains an error and needs to be fixed?
Create an OMNI intent
How many days (from the denial date) may a provider submit a new request if they choose not to pursue P2P or appeal?
Day 61 from the denial date.
True or False — Notes are optional if you create a task for modification.
False. Notes are always required.
What’s a best practice for ending a call?
Ask the caller if they any additional assistance and recite the state plan branding closing
What law protects members’ private health information?
HIPAA
Name one situation where an OMNI intent must be created.
Missing approval letter, new auth attached to existing auth or request in FileNet is needing creation.
IP vs OP: An auth that starts as OP for inp services/surgery converts to IP when receive what notification?
IP Admission notification
Name three elements you must always include in an escalation request.
Member details, provider details, and clear supporting notes.
True or False: Please use verbiage such as, “I will be happy to help you with that”, after a provider has stated their concern.
True
What should you do if the caller fails verification?
Politely decline to share any PHI.
What should you do with Behavioral Health calls?
Transfer to the Behavioral Health Team
What should you check before telling a caller there is 'no auth on file' for a status check?
Check member notes, then filenet. Make to verify the fax date if still not found
What should the provider be advised, if they want to change the priority level from standard to Urgent?
The provider will need to fax in clinicals, supporting the reason for the urgency.
Why is active listening essential during calls?
It ensures accuracy, reduces repeat calls, and builds trust.
What details must always be included in call notes for compliance? (Hint: 5 Ws)
Who, what, when, where, and why,
Can a P2P be scheduled the same day?
No