Provider Portal Online Authorization Guidebook 2018 PortalGuide-00-13-021918 Effective 1/1/18 Clarification update: 2.19.2018
Contents Online Authorization Introduction 3 High Level Overview Online Authorization Submission Process 4 Prior Approval Requirements 5 Member Search Highlights 6 Provider Search Highlights 7 Technical Tips 8 Submitting Authorizations: Step-by-Step Guide: Access the Authorization Portal 9 Step 1: Select a Member and classifications 10 Step 2: Complete detail fields 15 Step 3: Document medical necessity 21 Step 4: Attach supporting documentation 28 Step 5: View confirmation and print PDF summary 30 Searching for submitted authorization status 32 This document is searchable: For PC Users: Hold down the Ctrl and F keys at the same time, or click on the Binoculars icon, to open the search pane. For Mac Users: Hold down the Command and F keys at the same time, or click on the Binoculars icon, to open the search pane. Type in the first few letters of the topic you are seeking, and click Enter. Continue to click on the Arrow in the search pane to scroll through the matches within the document. 2
Introduction Welcome to our Online Authorization service. Community Health Options Medical Management Department is pleased to announce our partnership with HMS and MCG Health to create a self-service documentation platform for providers to submit authorization requests online. HMS web-based software (Essette Suite) enables providers to initiate online authorizations, track status of requested online submissions, and print verification of authorization decisions for requests that are submitted through our Provider Portal. HMS integration with MCG Care Guidelines: The MCG Cite AutoAuth module gives providers the opportunity to provide clinical details, which is guided by MCG s evidence-based clinical criteria, in support of the authorization review process. Thank you for being one of our trusted partners. 3
High-Level Overview of Online Authorization Process Step 1: Select a Member and classifications. Select the Submitting Provider name/address. Choose Authorization Classification (Ambulatory/ Outpatient, DME, Inpatient, Transportation). Choose Authorization Sub-classification (i.e., Diagnostic/Consult, Home Health/Hospice, etc.). Choose Member (requires exact match on three identifiers: Last Name, Date of Birth, and first 10 characters of Member ID). Step 2: Complete detail fields. Confirm Requesting (Submitting) Provider chosen in Step 1; please verify Provider Name and address. Choose Servicing Provider: Individual Provider: use Provider s NPI (select the correct Provider address) or name. Facility: search by facility name using Health Options unique Facility ID number Enter Diagnosis code(s): use ICD-10 code(s). Enter Service code(s): use current CPT or HCPCS codes. Ambulatory/Outpatient Procedures: requires submission of CPT/HCPCS code(s). Inpatient Admissions/Observation stays: requires submission of at least one Diagnosis but it does not require submission of CPT/HCPCS code(s). Enter Date of Service: Pre-service (date of service is in the future): enter tomorrow as start date. Concurrent service (service is already underway): enter today as the start date. Post-service (service is already completed and patient is discharged from care): enter the first date of service as the start date Step 3: Document medical necessity. Select primary CPT/HCPCS code. Launch CareWebQI. This brings you to the medical guideline. Select all clinical indications that apply for that guideline. When all applicable indications are chosen, click submit. Step 4: Attach supporting documentation. At this step you will need to add supporting clinical documentation (e.g., clinical notes, diagnostic results, etc.). Submit Electronic and/or Paper documents. Electronic Documents: only PDF files under 40MB are accepted electronically. Paper: print fax cover page; fax the cover sheet with applicable clinical notes to our Medical Management toll-free fax number at (877) 314-5693. Step 5: View Confirmation and PDF summary. View confirmation that the authorization was successfully submitted. Reference Number (tracking number). Authorization Status: Received (this confirms successful submission to Health Options). Print PDF Summary that includes an overview of the submitted authorization request: Member and provider information. Authorization classification. Authorization sub-classification. CPT/HCPCS code(s). Number of requested units for each requested service line.. Need Assistance? Workflow/Technical Issues: Call Medical Management at (855) 542-0880, Monday-Friday, 8am-5pm. Member Search: Call Member Services at (855) 624-6463, Monday-Friday, 8am-6pm. Provider Search: Call Provider Relations at (207) 402-3347, Monday-Friday, 8am-5pm. 4 Return to Contents
Prior Approval (PA) Requirements Providers can locate our Notification and Prior Approval requirements on our Health Options website or through our Provider portal. Below is a list of our online Prior Approval requirement documents: Prior Approval Overview & Notification (effective 1/1/18) Medical Prior Approval & Notification Requirements Quick Reference Guide (effective 1/1/18) Durable Medical Equipment Prior Approval Requirements Quick Reference Guide (effective 1/1/18) Behavioral Health Prior Approval & Notification Requirements Quick Reference Guide (effective 1/1/18) Medications Prior Approval & Notification Requirements Quick Reference Guide (effective 1/1/18) PA options that are not available through this portal: Behavioral Health (BH) authorizations are processed by Behavioral Health Care Program (BHCP). A list of BH Prior Approval requirements are listed in our online Behavioral Health Prior Approval & Notification Requirements Quick Reference Guide. Behavioral Health authorization contact information: Fax: (207) 761-3079 Phone: (855) 481-7047 Medication authorizations (when drugs are dispensed by a pharmacy) are processed by Express Scripts. A list of covered pharmacy medications can be found in the Formulary Guidebook located on the Health Options website. Pharmacy authorization contact information: Fax (877) 329-3760 Phone: (800) 753-2851 evicore Authorizations (As of 1/1/18) Advanced imaging, cardiac imaging, ultrasounds, Spine and joint surgeries, pain management, and outpatient PT, OT, Speech, and Chiropractic therapies A list of evicore Approval requirements are listed in our online evicore Medical Prior Approval Requirements Quick Reference Guide (effective 1/1/18) evicore Prior Authorization Department: Phone: (855) 316-2673 evicore Portal: https://www.evicore.com/pages/providerlogin.aspx 5 Return to Contents
Member Search Highlights PLEASE NOTE: Authorization approval is not a guarantee of payment. Provider must verify Member eligibility on date of service. Online authorizations are only available for eligible Community Health Options Members. You are required to enter three unique identifiers for each Member: Member s last name, date of birth and first 10 characters of their ID number. The entered information must be an exact match to our eligibility data. This safeguard is in place to minimize the risk of selecting the wrong Member (patient) which could result in a privacy (HIPAA) violation. When searching for a Member, it is important to know that only our current Members will be found in this online database. PLEASE NOTE: If you are unable to find a Member using the required online search criteria, please contact Member Services for further assistance at (855) 624-6463, Monday-Friday, 8am 6pm. Online authorizations are not available if the Member is not eligible for benefit coverage. You will not be able to find individuals who have enrolled with Health Options but whose benefit coverage start date is in the future. Examples: Individual enrolls with Health Options by December 15th for January 1st coverage. Provider attempts to submit an authorization (for a service scheduled in January) on December 20th. The Member will not be in the online authorization system yet. The provider cannot submit an authorization for this Member prior to the January 1st coverage date. If you previously submitted an online authorization for a Member, and you are now unable to find the Member or the authorization history, it may be that the Member is no longer eligible for Health Options benefit coverage. Members who were previously covered by Health Options (no longer a Member) will not be found in our online Member search tool. PLEASE NOTE: If you are unable to find a Member using the required online search criteria, please contact Member Services for further assistance at (855) 624-6463, Monday-Friday, 8am-6pm. Member eligibility verification is required on the date of service: You must check Member eligibility through the Provider Portal or by calling Member Services at (855) 624-6463 on the date of service. The Member search function in this platform only lists individuals who are active Members on the date you are doing the search. PLEASE NOTE: Individuals found in our Online Authorization data base may be in the 2nd or 3rd month grace period. Due to system limitations, you will not be able to tell if the Member is in a grace period on this system. Therefore, it is essential that providers check Member eligibility status through the Provider Portal or by calling Member Services at (855) 624-6463 on the date of service. 6 Return to Contents
Provider Search Highlights Choosing the correct providers It is important to choose the correct providers to ensure authorization notification is sent to the intended provider at the correct service location to minimize risk of privacy (HIPAA) violations and Member dissatisfaction. The requesting and servicing provider may be the same if the requesting provider is also performing the service. Searching for In-Network (INN) providers (otherwise called a participating or par provider) Only Health Options direct-contracted providers will be found in the Online Authorization provider database. To maximize the efficiency of the INN provider search, use: NPI for individual providers. Facility ID number (unique Health Options ID number) for facility providers. PLEASE NOTE: If you do not see all of the providers names and locations that should be associated with your account, please contact your system administrator. Searching for Out-of-Network (OON) or Wrap (Wrap) Network providers If the servicing provider is a First Health Network (Wrap) or Out-of-Network (OON) provider, you will not be able to complete an online authorization request. When initiating an authorization request for a Wrap and/ or OON provider, please fax the authorization request to Health Options Medical Management team. Complete our online Notification and Prior Approval form, attach supporting clinical documentation, and submit the authorization request by fax to Health Options Medical Management team at (877) 314-5693. If you are the system administrator (e.g., super user) and you need to add a provider name and/or location, please contact Health Options Provider Relations at (207) 402-3347. 7 Return to Contents
Technical Tips System time out due to inactivity. The system automatically times out at approximately 15-20 minutes of non-activity to protect Member privacy. Please ensure you have enough time to complete the authorization submission once you start the online authorization process. Submission of clinical documentation is required. Electronic upload: uploads must be less than 40MB in PDF format. Paper submission: print Health Options fax cover sheet (found within the Online Authorization portal), attach clinical documentation and submit by fax to Health Options Medical Management team at (877) 314-5693. Internet Browser If you are using Internet Explorer (IE), the online authorization system works best with IE 8.0 or higher. Authorization Workflow support If you have questions about the online authorization workflow or you are having technical difficulties, please call our Medical Management team at (855) 542-0880, Monday through Friday, 8am-5pm. Member Search support If you have questions about finding a Member in the online authorization portal, please call Member Services at (855) 624-6463, Monday through Friday, 8am-6pm. Provider Search support If you have questions about finding an in-network (Health Options contracted) provider, please call Provider Relations at (207) 402-3347, Monday through Friday, 8am-5pm. 8 Return to Contents
Access the Authorization Portal I. Log in to Provider Portal II. Click in green banner Online Authorizations You will reach Community Health Options Online Authorizations Landing Page (screen shot below): 9 Return to Contents
Step 1 Select a Member and Classifications I. Submitted By This will be the provider who is requesting this service. It is important to choose the correct location for the chosen provider. A) Choose the drop down button in this field. This drop down should include all providers associated with the person who is actually submitting the online authorization. Please review for accuracy of provider name and address. If this is not accurate, the intended provider will not receive notification of the authorization status or decision. Please stop and contact our Provider Relations team at (207) 402-3347 for assistance. If the intended provider and correct location address is not available, please submit the authorization request via fax until the correct provider information is added to the Online Authorization portal by our Provider Relations team. The Notification and Prior Approval Form includes our toll-free fax number and it is located at the Health Options website. 10 Return to Contents
Select a Member and Classifications Step 1 II. Auth Class (Authorization Classification) This is the general type of authorization category (classification) that you are requesting: Ambulatory/Outpatient, Durable Medical Equipment (DME), Inpatient or Transportation. Each option will be explained in this section. A) Choose the drop down button in this field. B) Click on the option that best fits the authorization classification you are requesting. AUTHORIZATION CLASSIFICATIONS EXPLAINED Ambulatory/Outpatient: Choose this option for outpatient services and procedures such as surgical procedures, therapy, infusions, home health and home hospice, etc. DME (Durable Medical Equipment): Choose this option for durable medical equipment and supplies. Inpatient: Choose this option for inpatient admissions, observation stays in acute care facilities, acute rehabilitation facilities, skilled nursing facilities, inpatient hospice and long term acute care hospitals. Transportation: Choose this option for ambulance transports by LifeFlight of Maine (due to system limitations all other ambulance transportation requests must be faxed to our Medical Management department). 11 Return to Contents
Select a Member and Classifications Step 1 III. Sub-Class (Authorization Sub-Classification) This sub-category further defines the type of service. A) Choose the drop down button in this field. B) Choose the drop down options in this field for the auth sub-class. AUTHORIZATION SUBCLASSES EXPLAINED Ambulatory/Outpatient subclass options: Diagnostic/Consult Use this for any outpatient diagnostic service, outpatient procedures, advanced imaging, etc. Home Health/Hospice Use this for any home health or home hospice service. Other Use this for any service that does not fall in another category. Commonly used for outpatient surgeries (carpal tunnel, cataract, etc.) Outpatient Therapy Use this for any infusion/ injection or therapy done on an outpatient basis. PLEASE NOTE: The number of units for IV infusions/ injections is based on number of doses and not the units (e.g., mg, mcg) per dose. Observation Use this for any member under observation level of care. NOTE: New subclass coming soon. DME subclass options: Purchase Use this when submitting a request for a DME purchase (when designated rental period requirement is met, if applicable). Rental Use this when submitting a request for a DME rental request. Please review the online Durable Medical Equipment: Quick Reference Guide on HealthOptions.org website for details regarding Health Options DME rental period and purchase requirements. Inpatient subclass options: Acute Inpatient Use this option when submitting a service request for an acute care facility (e.g., hospital). Acute Rehab Use this option when submitting a request to an acute rehabilitation facility. LTACH Use this option when submitting a request for a long-term acute care hospital. Skilled Nursing Facility Use this option when submitting a request for a Skilled Nursing Facility (SNF). 12 Return to Contents
Select a Member and Classifications Step 1 IV. Member Search patient (Member). Click on the Member Search button to initiate the search for your A) This brings you to the Member search fields. Enter Member s last name, date of birth, and first 10 characters of their Member ID. PLEASE NOTE: These must be an exact match. If it is not an exact match you will get an alert (red exclamation mark) which means you need to correct the submitted information. Doe 13 Return to Contents
Step 1 Select a Member and Classifications MEMBER SEARCH FIELDS EXPLAINED All three fields are mandatory when searching for a Member. Member identification requires an exact match to Member s Last name, Date of Birth, and first 10 characters of their Member ID. Each field needs to be filled in fully and accurately. Last Name Enter Member s last name. Do not include first name. If Member s last name is hyphenated, type as it appears. Example: John Mills- Smith should be entered as: Mills-Smith. Date of Birth Enter Member s date of birth using this format: MM/DD/YYYY. Member ID Enter Member s first 10 characters of Member ID. The Member ID can include only numbers or a combination of letters and numbers. PLEASE NOTE: If the Member ID has fewer than 10 digits/characters, add one or more 0 (zero) at the end of the ID number until you reach 10 digits/characters. If the ID has more than 10 digits, only enter the first 10 digits/characters. Any authorizations for this Member that are submitted via the authorization portal (by the provider, or on the provider s behalf) in the past year will be listed in the section immediately below the selected Member. If another office or provider has requested services you will not be able to see these authorizations through the online authorization portal. PLEASE NOTE: The status of the previously submitted authorizations is noted for each authorization request (one line can represent several CPT/HCPCS codes). A) If you want to see more details on a particular authorization that is listed, you can click on the Authorization Number hyperlink: B) You are now ready to advance to Step 2. Click on the continue button in the lower right corner of this screen. You will see this symbol when the system is searching for information If you need to correct any Member information that was entered in error, choose modify. 14 Return to Contents
Complete Detail Fields Step 2 In this section you will enter the servicing Provider, Diagnosis(es), Service(s), Dates of Service, and Priority of the authorization request- routine or urgent. A) Member s PCP: This field is not functioning at this time and it will always default to NONE. Step 2: Complete detail fields. B) Requesting Provider: This field will auto populate based on the selection you chose in Step 1. Cick on this provider s name to see additional information to verify accuracy. If it is the wrong provider or location, use the modify button to change the selection. Step 2: Complete detail fields. C) Servicing Provider: This is a search field. Step 2: Complete detail fields. If you are searching for an individual provider s name, enter the provider s NPI number. You can search by provider name or partial name but you must verify you have the correct provider name, NPI, address. If you are searching for a facility, enter the facility unique ID generated by Health Options. You can search by facility name or partial name but you must verify you have the correct facility name, NPI, address. PLEASE NOTE: Please refer to the Facility ID Glossary for the unique Health Options 6-digit facility ID number. It is located on the Provider portal. 15 Return to Contents
Complete Detail Fields Step 2 If your search reveals more than one option, be sure to choose the correct location. To select the provider, click on the circle icon on the right side of the row you want to choose. PLEASE NOTE: The magnifying lens pulls up provider name, address and phone number. At the end of Step 2, you will be required to verify the accuracy of the Servicing Provider name and address before you move to Step 3. In-Network Providers: Health Options direct contracted providers and facilities. If you are unable to locate an in-network facility name, please call Provider Relations at (207) 402-3347 Out-of-Network Providers: First Health Network (FHN) or Out-of-Network (OON) Providers. PLEASE NOTE: You will not be able to search for a First Health Network or Out-of-Network Provider using this online platform. Our database only includes Health Options in-network Providers. If the servicing Provider is FHN or OON, please submit your authorization request via fax. Our toll-free fax number is listed on our Notification and Prior Approval Form located on our website. D) Diagnoses: This is a search field for entering diagnosis code(s). You will need to enter at least one diagnosis. You can enter more than one diagnosis by repeating these steps: Enter the ICD-10 code in the field labeled Add. Then click SEARCH. It is important that you select the correct ICD-10 code. If you are submitting the request on behalf of a provider, please make sure the provider gives you the ICD-10 code(s) that you will need to enter. If you search by words instead of ICD-10 code(s), more than one option may be displayed. It will be important that you then choose the correct ICD-10 code. You will need to select the to the right side of the row of the ICD-10 description that you want to choose. 16 Return to Contents
Complete Detail Fields Step 2 E) Services: This is a search field for entering CPT or HCPCS code(s). PLEASE NOTE: You will not enter a CPT or HCPCS code if you selected Inpatient as your authorization classification. For inpatient service requests, you will only enter the diagnosis code(s). For ambulatory/outpatient procedures, enter the CPT or HCPCS code for the type of service that is being requested. You will be able to enter more than one service code, but you will need to repeat the process for each code. If you search using words instead of a CPT/HCPCS code, it is important that you choose the right code as this is what our claims adjudicators will use to match the claims to an approved authorization request. Select the icon to the right side of the row to choose the code you want. PLEASE NOTE: This is where you will first see Service Code Flags associated with the CPT/HCPC code(s) that you have entered. The Service Code Flag gives you information about whether or not a Prior Authorization is required for the code(s) you have entered. While the flags give providers a quick reference guide as to whether or not a Prior Approval is required, providers should reference our online Notifications and Prior Approval Guidelines for further details regarding Prior Approval requirements. F) Dates of Service: This is a search field for entering the date(s) of service. You will need to enter a start date in the box. This should be the date of admission, date of procedure, or date of the request if not scheduled. You can enter the date in MM/DD/YYYY format or you can choose the calendar to select the date. 17 Return to Contents
Complete Detail Fields Step 2 SERVICE CODE FLAGS EXPLAINED PA required via Health Options PA required via BHCP Prior Approval (authorization) is always required. PA required via Health Options (except POS 11& 23) If Member is receiving this service in a Provider Office (POS 11) or in the Emergency Department (POS 23), no Prior Approval is required. If you do not know if the setting is POS 11 or 23, please submit service request for Prior Approval. PLEASE NOTE: Some codes that would never realistically be done in a Provider Office or Emergency Department have this flag due to internal processing rules only. No PA required (subject to benefit review) No Prior Approval (authorization) is required for this code. Although no Prior Approval is required for this code, the claim still undergoes internal claims review to ensure it adheres to all applicable benefit rules. Please refer to our Behavioral Health Quick Reference Guide: Prior Approval and Notification Requirements located on our website. The Behavioral HealthCare Program (BHCP) provides medical necessity review of applicable Behavioral Health services for Community Health Options Members. PA required via evicore The service requested requires a Prior Authorization through Community Health Options partner evicore. Please refer to our evicore Prior Approval Requirements located on our website. Submit appropriate authorization through evicore s Provider Portal. evicore provides medical necessity review of applicable services for Community Health Options Members Non-covered The requested CPT/HCPCS service code is excluded from Health Options Medical Benefit Coverage. 18 Return to Contents
Complete Detail Fields Step 2 G) Priority: This drop down field requires selection of routine or urgent designation. Emergency services do not require Prior Approval. If you choose urgent, you are personally attesting that the requested service is urgent based on the Member s clinical presentation. Only choose urgent when the clinical presentation could seriously jeopardize the Member s life or health, ability to regain maximum function, or subjects the Member to severe pain that cannot be adequately managed without the requested service. We do not process requests as urgent for provider or Member convenience. If urgent is selected inappropriately and it is clear to our Medical Management team that the request is routine, we will change the status to routine and process accordingly. Authorization Decision Turnaround Time Guideline: The below overview of authorization decision turnaround times is based on receipt of all necessary information (day of submission is considered day 0 (zero)): Urgent concurrent (e.g., ongoing inpatient care)- one calendar day Routine concurrent (e.g., ongoing outpatient services)- one business day Urgent Pre-service- two calendar days Routine Pre-service- two business days Retro-authorization- 30 calendar days 19 Return to Contents
Complete Detail Fields Step 2 H) Additional Information: You must enter your contact information in this field so we are able to contact you if we have any questions or need additional clinical information to process the authorization request. If you do not provide this information and we do not have sufficient information to render a decision, the decision may be denied due to lack of evidence of medical necessity. PLEASE NOTE: Type phone before the phone number and fax before the fax number so we know which number is phone or fax. Submit your name, phone number and fax number in this box. Please include area code if it is outside 207 service area. You can also use this free-text field (up to 2000 characters) to provide us with any additional information that will facilitate medical necessity review of this request. I) Completing Step 2 You must select SUBMIT AUTH REQUEST button on lower right of this page. J) Confirming Servicing Provider When you select SUBMIT AUTH REQUEST, you will see a pop-up window that requires you to confirm the Servicing Provider information is correct. By choosing Confirm you are attesting that you have confirmed this is the correct provider and address. This information is what we will use to generate notification to the Servicing Provider. PLEASE NOTE: If you are unable to confirm the provider s information and location are correct, select cancel and modify your Servicing Provider Selection. Once you click the Confirm button, Step 2 will be finalized and you will advance to Step 3. CAUTION: Once you advance to Step 3, you CANNOT go back and change any of the information in Step 1 or Step 2. 20 Return to Contents
Document Medical Necessity Step 3 I. The next step in the online authorization process is submitting clinical information to support the medical necessity review of the service request. This is where the HMS integration with MCG Cite AutoAuth Guidelines comes into play. When you see this screen, the primary CPT/HCPCS is automatically selected based on the first CPT/HCPCS you entered in Step 2. You can change this designation at this step if needed. A) You only need to review the list of codes and make a selection if there is more than one code listed in this box. Select the primary code by clicking on the bulls eye circle to the left of the code. B) Once you have confirmed the primary code, you are ready to link to the MCG Guidelines by clicking on the button just below this box that says LAUNCH CAREWEBQI. CAUTION: Do not click the red X on any of the following pages in step 3. If you do, your information will not be saved. 21 Return to Contents
Document Medical Necessity Step 3 II. The CareWebQI button will take you to the MCG window titled Authorization Request Review on the top of the page. PLEASE NOTE: The focus on this section is Document Clinicals in the lower right corner and the Disclaimers noted on the bottom of the page. The information that you see within the gray boxes on this screen is for internal purposes only. If any of these codes do not require Prior Approval, the orange Document Clinicals button will be grayed out and you will not be able to enter clinical information for that particular code. 22 Return to Contents
Document Medical Necessity Step 3 III. For any procedure code entered in Step 2 that requires Prior Approval, there will be a separate line titled Procedure Code with an orange box to the right of that line titled Document Clinicals. A) You will need to click the orange Document Clinicals button for each CPT/HCPCS code(s) you entered in step 2. Once you have clicked the Document Clinicals box you will land on the MCG guideline page. If the procedure code you selected has more than one clinical guideline option, you will need to choose the option that best fits the clinical indications for this Member. PLEASE NOTE: Guidelines will have a prefix (e.g, AC, HC, ISC, etc). These relate to MCG guideline product options that are available for that code. Please select the best option that fits your service request. MCG GUIDELINE PRODUCTS EXPLAINED AC: Ambulatory Care Choose this option if the service is provided as an outpatient procedure (this includes Durable Medical Equipment (DME) and Transportation). CCG: Chronic Care This option is for internal Medical Management use only. GRG: General Recovery This option is for internal Medical Management use only. ISC: Inpatient & Surgical Care Choose this option if requesting an acute care inpatient admission, observation stay or inpatient/outpatient surgical procedures. RFC: Recovery Facility Care Choose this option if requesting admission to an acute rehabilitation facility or skilled nursing facility. HC: Home Care Choose this option if the service involves Home Health. PLEASE NOTE: Our Medical Management team will review your selection and change it to a more appropriate guideline/setting if needed. 23 Return to Contents
Step 3 Document Medical Necessity B) Once you select a guideline option, a page titled Authorization Request Clinical Indication CPT (code #) will appear. See screen shot example below: You will usually see a list of conditions (please select ALL that apply). You can add a note by clicking on the yellow note page. This is free text and it gives you an opportunity to add pertinent clinical findings to support this selection. When you click on the note, this pop up will appear (enter your note in this box. is complete or Cancel if you do not want to add the note. Select OK when the note 24 Return to Contents
Step 3 Document Medical Necessity C) When you have finished selecting all of the clinical indications that apply to this Member s clinical presentation, click the Next button in the lower right corner of this page. PLEASE NOTE: If you are entering this authorization on behalf of a provider and you do not know which clinical indications apply, you can click on Next without documenting any clinical indications. Our Medical Management team will review the attached clinical notes to discern which clinical indications apply to this case presentation. You may be brought to one or more additional pages. Continue to document clinical indications and select Next in the lower right corner of this page. If you need to review what you entered on the previous page, select the Back button in the lower right corner of this page. D) If no MCG guideline applies for the code as in the below example, please type pertinent clinical information to support this service request. Then select Next. E) There may be more than one MCG guideline to choose from. If this is the case, choose the MCG guideline that best fits with the request that is being submitted. 25 Return to Contents
Document Medical Necessity Step 3 F) Guideline review. You are now ready to start the clinical review process by checking all applicable boxes that relate to this Member s presentation. PLEASE NOTE: By checking these boxes you are attesting that the information you are submitting is an accurate reflection of this Member s clinical presentation. Health Options Medical Management department periodically audits files and will compare against submitted clinical notes to verify online selections match submitted supporting clinical information. Our Medical Management team will review the authorization request against submitted clinical documentation to complete the medical necessity review. PLEASE NOTE: If you chose the guidelines but you do not have the clinical knowledge to complete the Guideline review, please choose the Next button in the lower right hand corner of each page of the Guideline. G) Continue to click Next to advance to the next page and continue your clinical documentation. You can select the Back button if you want to review the prior clinical documentation page. H) When you reach the end of the clinical documentation requirements, you will be brought back to the original Authorization Request Review page. Complete the above process for each additional procedure code line. PLEASE NOTE: The procedure line appearance has now changed. The orange button has been replaced with Edit Documentation and Remove Documentation. You can select either of these choices at this time. 26 Return to Contents
Document Medical Necessity Step 3 J) Once you have completed documentation for each of the procedure codes and you have reviewed ALL DISCLAIMERS, click the orange Submit button in lower right corner of the page. CAUTION: You cannot return to step 3 once you click submit. TIPS FOR DOCUMENTING CLINICAL INDICATIONS Depending on the diagnosis and/or procedure code or codes you submitted, you may be required to document the clinical indications for the Member s condition. You can select as many of the indications that are relevant to your Member s situation. You do not need to select any of the indications that are displayed if they do not apply. However, you must continue through each page of questions by selecting Next until you see the Authorization Request Review page again. Only codes that were designated as documentable on the original request appear on the Authorization Request page. Any other codes are considered to be informational only. You must document the clinical indications for each of the codes listed on this page. The Submit Request button at the bottom of the page will remain unavailable until the clinical indications for all codes have been documented. You only need to attach a specific guideline to your request once. If the same guideline is attached to more than one code on your request, your previous documentation for the guideline will be automatically included for the other code(s) where the guideline was selected. You cannot update the selected clinical indications for the other code(s). When you first open the Authorization Request page and/or upon completion of documentation, one or more Health Options disclaimers may appear for each procedure code. A disclaimer provides information related to the associated codes, request that specific documents be attached to the request to expedite internal medical necessity review, or detail some other required action. CANCEL AN AUTHORIZATION REQUEST For a draft authorization request which has the requested codes documented: On the Authorization Request page, select the Cancel Request link. A message appears, asking confirmation that you want to cancel the request. For a submitted authorization request: On the Authorization Request - Submitted page, select the Cancel Request link. A message appears, asking confirmation that you want to cancel the request. Select Yes. 27 Return to Contents
Attach Supporting Documentation Step 4 1. You are required to submit supporting clinical documentation for all ambulatory/ outpatient service codes. PLEASE NOTE: The only exception is notification of inpatient stay or observation less than 24 hours. Once the stay is 48 hours or longer, submission of clinical information is required. Ongoing inpatient reviews are not completed via the Online Authorization portal. These are typically completed via fax and phone communication with our Medical Management nurses. At this step you will be asked if you have supporting documentation to accompany this authorization request. If you do not provide supporting documentation, this may delay the authorization review process. A) Please select yes in the Select One drop down box (unless notification is being made in less than 24 hours inpatient admission/observation stay). B) You can submit documentation through the portal (electronic files) or through fax (paper documents) or both. 28 Return to Contents
Attach Supporting Documentation Step 4 If you choose electronic files: Click select Find and select the document in your files, then click Open. Click Upload Document to add the clinical notes to this authorization request. You will see the uploaded document referenced in the blue bar above the document search box. Select the Open link to preview the file. Select the Remove link to remove the file in order to upload a different file. Repeat as needed to add additional files. If you need to fax your clinical notes, choose Paper Documents in this drop down: Then select Print Cover Sheet. Fill out the cover sheet with any additional information you wish to add, attach clinical, and fax to our Medical Management team at (877) 314-5693 Once all documentation is uploaded, click continue. 29 Return to Contents
View Confirmation and Print PDF Summary Step 5 You will be brought to Step 5 to confirm successful submission of the authorization request. The authorization reference number is located just below the Step 5 ribbon. PLEASE NOTE: The Reference number is assigned is created in accordance with Health Options established protocols, so the numbers that you see may not be sequential in your list. They are, however, unique. You can use this number to identify the authorization request if you need to talk with us about the request. You will also note there is an authorization status of RECEIVED. This confirms successful submission. A) You can now print a PDF summary of your request. B) You can also start another authorization request by clicking the SUBMIT ANOTHER REQUEST button. 30 Return to Contents
View Confirmation and Print PDF Summary Step 5 Authorization Summary On the Authorization summary page you will see the diagnosis and procedure codes that you entered in Step 2. You may also see flags noted in the pink rows. These are Medical Management flags for internal program referrals. No action is needed by submitting provider. CONGRATULATIONS. You have now completed the submission process. 31 Return to Contents
Searching for submitted authorization status 1. You can search the status of previously submitted online authorization requests submitted by the provider or provider s designee. A) Click on the Authorization Search hyperlink located on the Online Authorization landing page. PLEASE NOTE: You will only be able to search authorizations that you have submitted through the portal. You will not see any authorizations submitted by any other providers or facilities nor any authorization started by fax or mail. PLEASE NOTE: Submitting authorizations through the online portal can ONLY be used for NEW requests and INITIAL inpatient notification. Any update or extension to a previously approved authorization will require a fax to the Medical Management team at: (877) 314-5693. This includes, but is not limited to: extending dates of service, changing quantity of units, changing providers, inpatient notification of a prior approved surgery, and additional clinical information to an existing online authorization request. By Clicking Authorization Search you will land on this page where you will find search fields. B) Enter Search Criteria in designated search fields. You are able to search by authorization (reference) Number, Member ID, Member Name, and/or date range, etc. C) Click SEARCH. 32 Return to Contents
OVERALL AUTHORIZATION STATUS EXPLAINED See explanation below for overall authorization status which may include multiple CPT/HCPCS codes on one authorization request. Approved Init The request is approved as initially submitted. Approved Sub The request is approved as a secondary (subsequent) request. Denied The entire authorization request (all inpatient days or all submitted CPT/HCPCS codes) is denied. In Process The authorization request is received and it is being processed by our Medical Management team. Incomplete Authorization request has been received, and it is in our Medical Management team s queue for processing. Modified The request is partially approved and partially denied. (Example: Three units requested: two units approved and one unit denied = modified.) Pended The request is being pended for further internal clinical review. Void The request is cancelled or withdrawn due to submission error, duplicate request, Member is not eligible for benefits or no Prior Approval is required. Withdrawn The requesting provider (or designee) requests to voluntarily withdraw the submitted request. 33 Return to Contents