Chapter 4 Health Care Management Unit 3: Requesting an Authorization

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1 Chapter 4 Health Care Management Unit 3: Requesting an Authorization In This Unit Topic See Page Unit 3: Requesting An Authorization Overview 2 Requesting an Authorization 3 Treatment Plan Submissions - Requesting Outpatient 5 Therapy Services Authorization for Medicare Advantage Members

2 4.3 Overview Authorizing Services In The Appropriate Network When requesting an authorization, be sure that the member receives care from a provider who participates in the network associated with the member s program. Electronic Authorization System Authorizations may be requested through NaviNet or by submitting a HIPAA 278 transaction through your practice s software. Electronic authorization requests are the preferred method and are quick and easy to perform. To learn more about how to request authorizations electronically access the Customer Care page on NaviNet. For a HIPAA 278 transaction, refer to the Provdier EDI Reference Guide on the Provider Resource Center. Medical Record Review Highmark reserves the right to request and review medical records for visits whether or not preauthorization is required. If such review determines that any or all treatments were not medically necessary, were not billed appropriately, or were not performed, a refund will be requested. If a refund is requested, the practitioner may not bill the member for the services. Utilization Decision Making Highmark makes utilization review decisions based only on appropriateness of care and service and the existence of coverage. They do not reward practitioners, providers, Highmark employees or other individuals conducting utilization review for issuing denials of coverage or service, nor do they provide any financial incentives to utilization management decision makers to encourage denials of coverage. Criteria Used Highmark uses McKesson Health Solution s InterQual criteria in its processes for assessing the medical necessity and appropriateness of health care services. The Interqual criteria are applied to assessment of acute adult, acute pediatric, acute rehabilitative, long-term acute, skilled nursing and home health services. These criteria are applied in conjunction with applicable Highmark Medical Policy, Medicare Advantage Policy, and Highmark Medicare Services Administrative Policy. Note: If you would like more information about the criteria used for determinations, please contact HMS at Continued on next page 2

3 4.3 Requesting an Authorization How to Request An Authorization Follow these steps to request an authorization. Step Action 1 Electronic Non-Electronic submissions Submissions What Region Am I? Use NaviNet or HIPAA 278: NaviNet guides the user through the steps. For information about using the 278 transaction, refer to the Provider EDI Reference Guide in the Provider Resource Center. Call HMS at one of the following telephone numbers to request an authorization: Western Region: , option 2 Erie , option 3 Johnstown , option 3 Central Eastern and Northeastern Region: Central, Eastern and Northeastern Region Specialists should continue to call Western Region Specialists should call , Option 2. For behavioral health services, contact Highmark Blue Shield s Behavioral Health Unit at Provide HMS the following information about the patient: General information (name, age, gender, etc.) Member identification number Medical history Any comorbidity All pertinent medical information (test results, prior treatment, etc.) Presenting symptoms Acuity Diagnosis Service to be performed, including admission or procedure dates and location Names of any other health care providers involved in the care Proposed length of stay and frequency or duration of services Treatment plan and goals Psycho-social issues impacting care Discharge plan Note: The HMS reviewer may request additional information. Requests may be denied for lack of information. Continued on next page 3

4 4.3 Requesting an AuthorizationContinued How to Request An Authorization (continued) Step Action 2 HMS reviews the information. The decision-making period begins once HMS has received the request. If the request is for a A decision is made within Pre-certification authorization 1 calendar day for urgent care 2 business days for non-urgent care Concurrent inpatient No later than 1 business day authorization Note: If you would like more information about the criteria used for determinations, please contact HMS at Following review, HMS either authorizes or denies coverage for the request. If the request is approved If the request is denied You will be notified through Referral/Authorization Inquiry in NaviNet or through your practice s software. If you do not have access to NaviNet, you will receive a paper report through the mail. You will be advised of your appeal rights and the option of requesting a peer-to-peer conversation with the physician advisor who made the decision. 4

5 4.3 Treatment Plan Submissions - Requesting Outpatient Therapy Services Authorization for Medicare Advantage Members The Process The following services require authorization from the initial visit, and a subsequent treatment plan after the 12th visit: Physical therapy Occupational therapy Speech therapy There are two ways a request may be submitted for physical or occupational therapy: via NaviNet, or by phone. NaviNet Submissions: Physical Therapy and Occupational Therapy Step Action 1 Hover over the Referral/Auth Submission button on Plan Central 2 Select the Treatment Plan fly out button 3 On the Request Form, the instructions are printed at the top. Providers reporting for 12 visits or less within the current calendar, year should complete Part 1 only Providers reporting for greater than 12 visits within the current calendar year should complete both Part 1 & 2. When visits since the beginning of the year are in question, always complete both Part 1 & 2. 4 If you need additional training on how to submit a Treatment Plan request, contact NaviMedix Customer Care at Phone Requests Call the HMS Care Management automated telephone system: Pittsburgh Region: , option 2 When prompted, select the therapy pathway. Erie Region: Johnstown/Altoona Region: Central, Eastern, and Northeastern Regions: What Region Am I? Continued on next page 5

6 4.3 Treatment Plan Submissions - Requesting Outpatient Therapy Services Authorization for Medicare Advantage Members, continued NaviNet Submissions: Speech Therapy Step Action 1 The authorization request to begin treatment must be initiated by the member s physician who is requesting the therapy services. 2 Hover over the Referral/Auth Submission button on Plan Central 3 Select the Auth Submission fly out button 4 On the Selection Form, select the Category of Outpatient and Service of Speech Therapy from the dropdowns 5 If a plan of treatment has already been developed by the speech therapist, that information can be entered into the Request Form comment block titled Treatment Plan. 6 Submit the request to HMS 7 Beginning with the 12th visit, an additional treatment plan will be necessary. HMS will contact the speech therapist with a request for information about the member s treatment plan. Telephonic Submissions: Speech Therapy Step Action 1 The authorization request to begin treatment must be initiated by the member s physician who is requesting the therapy services. 2 Call the HMS Care Management automated telephone system: Pittsburgh Region: , option 2 When prompted, select the therapy pathway. Erie Region: Johnstown/Altoona Region: Central, Eastern and Northeastern Regions: What Region Am I? Hover over the Referral/Auth Submission button on Plan Central 3 Beginning with the 12th visit, an additional treatment plan will be necessary. HMS will contact the speech therapist with a request for information about the member s treatment plan. 6