NEW AUTHORIZATION REQUEST USER GUIDE. For Premera Blue Cross Medicare Advantage Plans providers using Clear Coverage

Transcription

1 NEW AUTHORIZATION REQUEST USER GUIDE For Premera Blue Cross Medicare Advantage Plans providers using Clear Coverage 1

2 CLEAR COVERAGE NEW AUTHORIZATION REQUEST USER GUIDE 1. Log into One Health Port (OHP) and then into your Provider Portal. a. Clear Coverage (CC) will be on the navigation tree. b. The first time you log into Clear Coverage you will need to accept the user agreement. 2. After logging into Clear Coverage, the Main Menu will include several tabs a. Home b. Authorization Search c. New Authorization d. Administration Not used 2

3 3. Select NEW AUTHORIZATION tab to open a new request. 3

4 4. Step 1: Patient Search search for a patient by entering as much criteria as possible. a. Enter: Last Name, First Name, or Subscriber ID, or Date of Birth or Gender or all at once. i. Note: Entering a subscriber ID is typically the fastest way to pull up a record. b. Click the Search button. 4

5 c. When patient s name (or names) comes up, verify DOB, Eligibility to make sure correct patient is chosen. d. Once correct patient is verified, click Select button located at the left of the name. 5. Patient Information Verification and Selection verify patient information. a. Verify that the correct patient has been selected. b. Click the Add to Request button. c. The patient information will be added to the Authorization Request on the right side of the window. 6. Step 2: Requesting Information - Search for a physician/provider requesting the Authorization. a. The Facility Name will auto populate with your specific clinic or provider information. b. For Requesting Clinician: i. Choose Select Other Clinician 1. Enter physician name and click Search. 2. Locate the correct provider if more than one is listed. 5

6 3. On far lower left-hand side, choose box that is labeled Add Selected to Preferred Clinician List. 4. Click Use Selected. This will bring the name over to the Requesting Clinician field. ii. Once the clinician list is populated, click the drop down arrow to choose the requesting clinician for future Authorization Requests. iii. The specialty and NPI will auto populate. 6

7 c. Date of service i. Let the date default to the date of entry - CC is set for a 6-month time span on all Authorization Requests. ii. Procedure dates up to 3 months in advance can be scheduled. iii. The calendar will not accept retro dates of service. d. Click Add to Request. 7

8 7. Step 3: Diagnosis- Select up to 3 diagnoses that are appropriate for the service for which you are requesting Authorization. a. Search for diagnosis by typing in key word or diagnosis code number, including decimal point. b. Click Add. c. Click Next. d. The diagnosis will be added into the Authorization Request on the right-hand side. 8

9 8. Step 4: Service- Select the procedure for which you are submitting an Authorization. a. To find the procedure for which you wish to request authorization: i. Type in the code in the Service Lookup box (example: ). (OR) ii. Type a portion of the procedure name in the Service Lookup box (example: Fusion, lumbar spine ). 9

10 iii. Enter ONE main code for the procedure you are requesting. Please enter only ONE CPT/HCPCS code at this time. Entering more than one will create a duplicate request. Enter the additional code(s) that you are requesting in the Additional Notes section (See Step 6 below). iv. Click Add. v. Click Next. vi. The procedure will be added to the Authorization Request on the right-hand side. b. If that specific code is NOT in CC use in the Service Lookup box. This will display as Unlisted. i. Click Add. ii. Click Next. iii. Enter the code(s) that are being requested into the Additional Notes section. We will enter the code(s) on our side when the Authorization Request is created in our system. 10

11 iv. If you select the wrong procedure, click on the trash icon next to the procedure to delete the selection from you list and choose again. c. NOTE: Some procedures require Medical Review. This will be indicated in the righthand column just below the procedure requested under Medical Review. If a review is required you will see Required to Submit. This can be completed in #9 Step 5: Service Information below. 11

12 9. Step 5: Service Information a. There are multiple steps in this section. i. Priority ii. Diagnosis iii. Service Facility iv. Details v. Medical Review 12

13 b. Priority can be changed with the drop down. c. Diagnosis nothing needs to be done. d. Service Facility For in-plan facilities: i. Click Change in search box, enter the facility where the services are to be done. ii. Click Filter. iii. Select the button at the left of the facility name. Be careful to choose the correct facility as there may be two or three with similar names. 13

14 iv. NON-PAR (out-of-plan) FACILITY: 1. Enter name of facility. 2. In the drop down menu under In-Plan, select All. 3. Click Filter. This will allow selection of the non-par facility. 4. Select button at the left of the facility name. 14

15 5. If the non-par facility is not on the drop down menu, a. Enter nonpar in the Name field. b. Select All in the drop down menu. c. Select Filter. 15

16 d. Select NON PAR FACILITY PROVIDER ADD. e. Then make sure to enter the name of the facility in the Additional Notes section. v. IF PROCEDURE IS TO BE DONE IN THE OFFICE: 1. Enter nonpar. 2. Click All in the network drop down menu. 3. Select Filter. 16

17 4. Select NONPAR FACILITY PROVIDER ADD. 5. In Additional Notes enter that procedure is to be done in the office. 17

18 e. Details i. This section must be completed when the exclamation point is visible. It will be visible when: 1. The patient requires a referral to a specialist. 2. When the procedure requires Units of service such as eye injections. a. Click Details. b. In Referral Provider Select the specialists name ( the name of the provider performing services) from the drop down menu c. In Referral Number enter the referral number to the specialist. d. Click OK. ii. If for some reason a referral is not required, such as with seamless clinics, enter Not required. 18

19 f. Medical Review: i. Perform Medical review if available and required. 1. Click Required to Submit button on left screen. 2. To complete, follow the prompts until you reach the Result Screen. 19

20 ii. On the Result page: 1. If the Medical Review is Not Recommended and you want to continue with the Authorization request, select Continue. 2. Click Finish. 3. If you do not want to continue with this request just click Finish and it will be removed from request. 4. If the Medical Review is Recommended, click Finish. 20

21 21 (OR)

22 g. If all the required steps in Service Information have been completed, click Next. 10. Step 6: Additional notes - this is the section that is most important for communication to Premera Blue Cross on how to pay the claim. a. Enter the following information: i. ANY/ALL ADDITIONAL CPT codes ii. Facility if used NONPAR iii. Please indicate if your request is for INPATIENT/OUTPATIENT/ OFFICE iv. Dates span ONLY IF YOU ARE REQUESTING DIFFERENT THAN THE STANDARD 6 MONTHS v. ANY information you need to give to us in order to process the request vi. Your name and phone number so we can contact you if we have questions b. Click Add Note/Attachments. More than one Note entry may be necessary, particularly if chart notes are being attached. 22

23 c. ADDING CLINICAL INFORMATION: i. BROWSE BUTTON: 1. Click Browse. 2. Select document you wish to attach. 3. Type information about what is being attached in the Additional Note field. (Example: Clinical information attached). 4. If you decide you do not want to attach the document, click the red circle with white x to delete. 5. Click Add Note/Attachment. Once you click Add Note/Attachment, you will not be able to delete the attachment. 6. USE SEPARATE NOTE FOR EACH IMAGING REPORT. 23

24 ii. COPY AND PASTE CLINICAL INFORMATION 1. Enter date of office visit at top of Note entry. 2. Enter name of physician providing service. 3. Enter up to 4000 characters. 4. If information goes above the 4000 characters, click Add Note/ Attachments. 5. Continue at the top of next page. a. Enter date of office visit at top of new page. 6. USE SEPARATE NOTE FOR EACH IMAGING REPORT. 24

25 iii. FAX COVERSHEET: 1. In lower left-hand corner click Save and Print. 2. Click Fax Coversheet. 3. In Print Fax Cover Sheet dialogue box, enter any note you would like to describe information being submitted. (Example: MRI/Chart notes) 4. Click Print Coversheet. Follow instructions on the coversheet using the fax number specified. 5. If the Fax Coversheet does not appear, you may have to unblock popups. 25

26 SEE ATTACHED SAMPLE COPY OF FAX COVERSHEET AT END OF USER GUIDE. 26

27 iv. After all Notes and information have been attached you can now click Submit on the lower right-hand side. 1. A window will appear listing the Service, Case Reference # and Request Status. (We do not use Reference # for the Authorization process). a. Service: Lists what procedure is to be done. b. Case Reference # is use to identify the Authorization request whether it Approved, Pended or Denied. c. Request Status: This will indicate if the Authorization request is Pending or Approved. Denials are not listed here. Denials will be displayed in the Activity column as a Payer Added Note in the Home screen. 2. Would you like to create another Authorization Request? question. a. This allows you to generate another Authorization request for this patient. Click No if you do not have any. b. Information regarding the Authorization Request will now appear in the Home screen and in the Authorization Search screen. 27

28 d. ADDING ADDITIONAL INFORMATION AFTER AUTHORIZATION HAS BEEN SUBMITTED OR SAVED. i. DENIED FOR LACK OF INFORMATION. AT THIS TIME YOU WILL NEED TO SEND IN DOCUMENTATION IN THE TRADITIONAL METHOD AS IT CANNOT BE SENT THROUGH CLEAR COVERAGE. FAX INFORMATION TO AS PREVIOUSLY DONE PRIOR TO CLEAR COVERAGE. MAKE SURE TO WRITE ON THE FORM THAT THIS IS ADDITIONAL INFORMATION AND NOT A NEW REQUEST. ii. ADDING MORE INFORMATION: If you get a request from us for more information, for example, and the request is still open and pending, you can submit more information via the Notes sections using the Browse, Fax Coversheet or cut and paste functions. However, you will need to make sure you click on the Save button to have it come over to us. It will show up in the Notes section on the right-hand side and you will see it, but if you do not Save it will not come over to us and we will not be able to see it. 28

29 11. Home Screen a. This screen will display the multiple steps entered in this Authorization Request. b. This screen will also display: i. COMMUNICATION FROM PREMERA BLUE CROSS. IT WILL APPEAR AS A PAYER ADDED NOTE IN THE ACTIVITY COLUMN. (THE COLUMN HEADING MAY NEED TO BE EXPANDED TO VIEW FULL COLUMN) THIS MAY BE A REQUEST FOR ADDITIONAL INFORMATION IF THE AUTHORIZATION REQUEST IS IN THE PENDING STATUS. IT IS IMPORTANT THAT THIS SCREEN AND COLUMN IS MONITORED THROUGHOUT THE DAY. ii. Approvals and Denials are displayed in this screen as well. c. To open the Authorization Request, click Detail button. 12. Authorization Search Screen a. This screen lists the Authorization requests one line per request. b. Authorization requests are kept in the system for up to a year. c. The Authorization requests can be sorted and searched for by Status (Authorized; Auth Denied; Auth Incomplete, etc.). d. To open the Authorization request, click Detail button. 13. Canceling a request. a. Open up request. b. At bottom right-hand corner click Modify Request. c. Select Cancel Request. 14. To Print Summary of request a. Open Authorization request. b. In lower left-hand corner click Save and Print. c. Select either the Full or Summary version. 15. How to find the Authorization number. a. This is called the Case Reference Number. i. It can be found immediately after you click Submit. ii. After the request has been submitted, you can also find the number in the righthand column under Authorization Request Service 1 Status screen. iii. It is also displayed in the Summaries mentioned in #14 above. 16. Troubleshooting The Submit Button is Disabled / Grayed Out In order to Submit an Authorization Request, all the required information needs to be entered. Retrace your steps and double check the following items: 29

30 a. Date of Service i. The date of service start date defaults to the date of entry of the request. If you Save the request, but do not Submit, and do not complete it on the same day, you will need to change the date to the date of completion. Use the calendar to the right of the date field to select the current date. b. Patient eligibility c. Clinician is entered d. At least one diagnosis code is in the Diagnosis Section. e. A Procedure is listed f. A Service Provider (hospital, ambulatory surgery center, office) is associated with the Procedure. i. If a Procedure is added or changed after the Service Provider (hospital, ambulatory surgery center, office) is selected, it will not have a Service Provider assigned to it. You will need to enter the facility/office again. g. The Detail section has been completed if required. h. The Medical Review has been complete if required. Jean M. Economen, RN June ( ) 30