Payers (BCBS, UHC, etc)
Providers can track the status of a prior authorization request by logging into this platform.
What is the UnitedHealthcare Provider Portal?
Name 2 things that are required to prove conservative treatment is met prior to a Total Knee Arthroplasty.
1) Medications – Use of anti-inflammatory drugs or analgesics to reduce pain and inflammation.
2) Physical Therapy – Strengthening exercises and activity modification to improve mobility and reduce strain on the knee.
3) Weight Management – Counseling on weight reduction if excess weight is contributing to knee pain.
4) Injections – Corticosteroid or hyaluronic acid injections to provide temporary relief
A decision made by a Medicare Administrative Contractor (MAC) regarding whether a particular medical service or item is covered under Medicare Part A or Part B on a regional basis. They define coverage criteria, including applicable CPT/HCPCS codes and ICD-10 codes that determine whether a service is considered reasonable and necessary.
What is a Local Coverage Determination (LCD)?
Agents should document their actions in Epic when they reach out to the health plan in this area.
What is the Epic Communication tab-Note
Healthcare providers must submit this type of documentation to justify the need for a requested procedure or service.
What are medical records?
BCBS Federal uses this Prefix on their Member ID #s.
What does an R in the member ID signify?
Name 2 things required by healthcare insurance companies to authorize an MRI w contrast
1) Physician’s Order – A formal request from the referring physician stating the medical necessity of the MRI.
2) Clinical Notes – Detailed records of symptoms, prior treatments, and failed conservative measures.
3) Diagnosis Codes (ICD-10) – Justification for the MRI based on diagnosed conditions.
4) Procedure Codes (CPT) – Specific codes for the MRI with contrast.
5) Alternative Imaging Results – Some insurers require X-rays or ultrasounds before approving an MRI.
6) Medical Necessity Statement – Documentation explaining why the MRI is essential for diagnosis or treatment.
A nationwide policy established by Medicare to define whether a specific medical service, procedure, or device is covered across the entire United States. Unlike Local Coverage Determinations (LCDs), which vary by region, these apply uniformly to all Medicare beneficiaries.
What is a National Coverage Determination (NCD)?
This Reason Code is used when a referral requires additional information from the clinical team.
What is Clinic Info Needed?
A prior authorization request may be rejected due to insufficient documentation, leading to this type of determination.
What is an adverse determination? Denial
This plan requires pre-certification for Specialty Pharmacy medications through Optum Portal
What is UHC
Before approving high-cost infusion therapy, insurers may require proof of prior testing, such as lab results or genetic screenings
What are Drug-Specific Requirements?
This Medicare eligibility response indicates a replacement coverage is available NOT MEDICARE part B
What is Patient is eligible for Medicare Advantage
When an authorization is obtained from a payer the agent should document the confirmation number they obtain in this field in order for it to print on the claim form.
What is Authorization tab-Auth # field?
If a prior authorization request is denied, a healthcare provider or patient may initiate this process to challenge the decision.
What is an appeal?
Name 3 portals that BCBS uses to submit prior authorizations to the Payor.
Carelon, Availity, Evicore, Quantum, Telligen, Cohere, Evolent
Name 3 things that must be documented when obtaining Benefits and Eligibility
1) Payor Name, Payor Phone Number (if call was placed), Case Number documented
2) Portal Name and screenshot (if portal was used)
3) Full Screenshot from the portal notification uploaded: PA Required/PA Not Required
4) Details of the call: Payor representative, call reference #
5) If prior auth is not required, is it a covered benefit, were all necessary options exhausted
6) In/Out of Network verified
7) If prior Auth is not required is Predetermination required/optional/not recommended
8) If prior auth required with clinicals requested were they uploaded/sent/documented/ successful facsimile transaction uploaded
9) If applicable to service ordered, Buy & Bill Allowed or Specialty Pharmacy
10) For OOS plans and Labor funds - was a call placed
When pulling a Medicare article, what does the "-" in between 2 diagnosis codes, indicate.
What is diagnosis code range
Ex:
ICD-10-CM Codes included in Range M08.80 - M08.99
ICD-10-CM Code ICD-10-CM Code Description M08.80 Other juvenile arthritis, unspecified site M08.811Other juvenile arthritis, right shoulder M08.812 Other juvenile arthritis, left shoulder M08.819Other juvenile arthritis, unspecified shoulder M08.821Other juvenile arthritis, right elbow M08.822Other juvenile arthritis, left elbow M08.829Other juvenile arthritis, unspecified elbow M08.831Other juvenile arthritis, right wrist M08.832Other juvenile arthritis, left wrist M08.839Other juvenile arthritis, unspecified wrist M08.841Other juvenile arthritis, right hand M08.842Other juvenile arthritis, left hand
This field in the referral communicates where the service is being requested to be performed within the Location listed.
What is POS Type?
Insurance payers often use this term to describe the conditions that must be met for a service to be approved.
What are medical necessity criteria?
This phone number is utilized to route calls to the appropriate payer States for Eligibility/Benefits
What is BCBS Provider Line 800-676-2583
Before approving high-cost medications or infusion therapy, insurers often require proof that these treatments were attempted and failed.
What is Alternative Treatment Documentation?
These articles can be found on the CMS web portal; however, they do not directly support medical necessity.
What is "NOT AN LCD REFERENCE ARTICLE "
Articles are a type of document published by the Medicare Administrative Contractors (MACs). Articles often contain coding or other guidelines and may or may not be in support of a Local Coverage Determination (LCD).
Articles identified as “Not an LCD Reference Article” are articles that do not directly support a Local Coverage Determination (LCD). They do not include a citation of an LCD. An example would include, but is not limited to, the Self-Administered Drug (SAD) Exclusion List Articles. If you have a question about this kind of article, please contact the MAC listed within the Contractor Information section of the article.
Articles which directly support an LCD are known as “LCD Reference Articles”. The referenced LCD may be cited in the Article Text field and may also be linked to in the Related Documents field. Examples may include but are not limited to Response to Comments and some Billing and Coding Articles. If you have a question about this kind of article, please contact the MAC listed within the Contractor Information section of the article.
The office changes this field if the services need to be done URGENTLY.
What is Priority?
A prior authorization request may be denied, or the patient may be asked to pay for services if the requested service is deemed to fall under this category.
What is experimental or investigational treatment?