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 is an SDOH NBA and how is it different from the SDOH intent.
SDOH Next Best Action- NBA is a service alert advising the member needs to be screened for SDOH needs and possible community resources.
What is the TAT for a standard authorization?
OH- 10 business 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?
Escalated Tracking System (ETS)
and/or
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 - 855-812-9215
March Vision - 844-916-2724
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.
Medication- ASMANEX HFA AER 100 MCG
Service date- 2/3/2021
Last filled- 1/10/2021
Rejection Reason- 88
Why was this Pharmacy Claim rejected?
Member tried to fill the medication too early.
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?
ICUE >> History Tab
OR
Maestro >> Referrals & Authorizations
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
Medication- GG/CODEINE SOL 100-10/5 420.0
Service date- 3/31/2023
Last filled- NA
Rejection Reason- 41
Why was this Pharmacy Claim rejected?
Member has an alternate insurance on file. Pharmacy needs to bill both insurances or the alternate insurance must be removed.
Name a technique to get an honest and candid response from members while completing a SDOH NBA?
1) Dont make it sound like a survey
2) Be conversational and use empathy
3)Some questions in the NBA are for the advocate and should not be read aloud
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?
Billing Grievance
How long after receiving the Notice of Action (NOA) does a member have to file an appeal?
60 days
Medication- MULTIVIT/FL CHW 0.5MG 60.0
Service date- 1/23/2020
Last filled- NA
Rejection Reason- 76 (Limitation of 1 per day)
Why was this Pharmacy claim Rejected?
Plan only covers 1 dose per day for the member and the prescription is for a quantity of 60 for 30 days. (2 per day), which exceeds the plan limitations.
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