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.).
Where can referrals on file be viewed by an advocate?
Prior Auth's & Referrals Intent in Maestro
What is the TAT for a standard authorization?
3 Business Days OR 72 Hours
What is the claims processing timeframe?
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.
Which NY plan does NOT require a referral for a member to see a specialist?
Essentials (EPP) plan
Where do you find authorizations for Vision and Dental Services?
Call the corresponding department:
UHC Dental - Dental
March Vision - Vision
How can you identify if the member received a Bill or an EOB?
Ask member if the statement came from UHC or the provider.
UHC does NOT send bills to members.
What does it mean to expedite an appeal?
The caller requests a faster response when processing their appeal.
What Maestro intent is used to check on prescriptions that have been rejected by the Pharmacy?
Pharmacy Claims Intent
Where in Maestro can an advocate check to see if referrals are required for a member's plan?
Plan Tab
Where would you find a decision on a medical authorization?
ICUE > History 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?
Fair Hearing or External Appeal
What system is used to review a Pharmacy Authorization that has been submitted to UHC?
RX Claims
What does the COB abbreviation stand for and what does it mean?
Coordination of Benefits
Determines the order in which an insurance will pay when there is more than one coverage.
After advising a member that an authorization was denied, what option does the member have available to them if they do not agree with the decision?
Appeal
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
What SOP can you use to assist you with any Pharmacy issues?
Pharmacy Call Handling Index - KM1227187
What 2 plans are NOT allowed to have other insurance? (OI)
CHP & EPP