Category 1
Prescription or procedure does not meet the necessary medical criteria or it is excluded in the patient's plan coverage
Denied
When you submit an authorization request the insurance carrier will assign a Case # for the request. When speaking about an authorization request we also commonly use the term "case" as an alternative to "request"
'Case' vs. 'Request"
Patient visits the provider's office. The doctor determines if a procedure, test, medication or device is needed
Patient
Fax
Authorization Tasks - Task that have not been started yet. They are newly created. It is a requirement that these tasks are initiated within 24 hours of submission
Initiation
If an authorization request is not immediately approved upon submission. It will usually go into a "Pended" status or phase where the insurance carrier may request additional information in order to consider it further
Pending
If an authorization request goes into Pended status it's usual that you will be asked to submit medical records to support the request. Once the records are received the case goes to a Nurse Reviewer for additional review and hopefully approval
Clinical Review
Name 3 information you have to provide when requesting an Authorization
Patient Name and DOB
Insurance Member ID #
Tax ID and provider NPI
Referring/Ordering Provider's Name
CPT code
Diagnosis Code
Type of setting procedure/test will be performed in
Servicing Provider or Location
Additional information found in patient chart and provider notes
Importance of Prior Authorization
Cost-share efficiency
Ensure that the prescriptions or procedure the patient is receiving is the proper treatment and is medically necessary
Ensure the patient's safety
Authorization - Tasks - Tasks that have been initiated with a payer. It is important to review notes from previous agents in order to understand actions that have already occurred and the next steps to come
Follow Up / In Process
The service is covered and can be rendered
Approved
If during the Clinical Review phase the Nurse Reviewers is unable to make a decision on the case, he/she may additionally refer the request and defer the decision to the insurance company's Medical Director
Medical Director Review
Prior Authorization Method - Payer's portal allow provider's to submit PA through specific applications or websites accessible by provider's offices
Standard Electronic Transactions
Authorization Tasks - escalation from a practice. they have a high sense of urgency - we must work these tasks within two hours of being escalated
RAR - Requisition Action Request
Types of Work - Requires an outbound call to be performed to the payer/TPA/nurse case manager for authorization initiation and/or follo up
Voice
If the Nurse Reviewer or Medical Director is unable to approve a request they mat indicate that a "Peer to Peer" review can be done: the ordering physician may contact the insurance company and speak with their physician or Medical Director to review the case details over the phone
Peer to Peer Review
The insurance will review the PA request and will send a notification letter to both the patient and the provider once determination is complete
Healthify Insurance
Prior Authorization Methods - Providers may contact the patient's provider specific line through _____. Pros: Reduce or eliminate delay in receiving approval
Telephone
Authorization Tasks - This means that the date of service is either the day it was submitted or the following day. Like RAR tasks, they have a high sense of urgency and must be worked within two hours of submission
SND - Same, Next Day
Types of Work - Does not require an outbound call to be made to the payer/TPA/nurse case manager as authorization request or status can be accessed via portal
Non-Voice
If an insurance company cannot approve a request because the underlying diagnosis and/or documented patient history/testing do not meet the carrier's clinical criteria.
Medical Necessity
Depending on the patient's insurance policy and requirements, provider's office will send a PA request to the insurance
Provider
Prior Authorization Method - Some policies allow providers to send PA to a _____. Pros: Establishes electronic audit trail
Secured Email
Referred to as Precertification; is a clinical review required by some Health Insurance carriers before a service is rendered. The process used by health plans to assess the medical necessity & appropriateness of medical treatment requested by a physician for a patient
Prior Authorization
Most Commonly Used Payer Websites
NAVINET
Magnacare
Cigna
Fidelis
Payspan
Optum
AIM Specialty Health
Evicore