NaviNet Authorizations transaction: Frequently asked questions 1 of 4 10/30/2017 These frequently asked questions (FAQs) were developed to assist you in navigating the new Authorizations transaction on the NaviNet web portal. Note: This document will be updated as additional information becomes available. 1. When attempting to submit an authorization request, I am seeing a Highmark screen that prompts me to enter a user name and password. Why? You may need to modify your trusted site web browser settings to include Highmark.com, IBX.com, NaviNet.com, and NaviMedix.com. Please review the Optimizing Your Browser and Adding Trusted Sites Guide, which can be found in the NaviNet Resources section of the Independence Provider News Center at 2. What types of authorization requests can be submitted through NaviNet? The following service types are to be submitted through NaviNet: Ambulance Land requests for non-emergency land ambulance transportation Chemotherapy Durable Medical Equipment (DME) Purchase DME Rental Emergency Room/Department (ER) Admission Home Health Home Infusion Infusion Therapy Medical Surgical Skilled Nursing Facility (SNF) requests for coverage for placement in a SNF (can only be submitted by SNFs) 3. How far in advance can I submit my authorization and can requests be submitted retroactively? Follow the submission time frames outlined below: Service type Future date maximum Retroactive date maximum Ambulance Land 30 days after current date 2 days prior to current date Chemotherapy 183 days after current date 2 days prior to current date DME Purchase/Rental 183 days after current date 2 days prior to current date ER Admission Current date 365 days prior to current date Home Health 30 days after current date 2 days prior to current date Home Infusion 183 days after current date 2 days prior to current date Infusion Therapy 183 days after current date 2 days prior to current date Medical Surgical 183 days after current date 2 days prior to current date SNF 30 days after current date 2 days prior to current date
4. Do I need to attest each time I view the Authorization Log? 10/30/2017 No, you only need to attest the first time you access the Authorization Log. If you need to modify the selected Tax Identification numbers for which you have previously attested, select the Edit supported entities/clinicians link from the Authorization Log. For additional details, please refer to the Authorization Log Guide, which can be found in the NaviNet Resources section of the Independence Provider News Center at 5. What requests can be viewed through the Authorization Log? Only requests submitted through NaviNet can be viewed through the Authorization Log. Please note that if you do not press Submit at the bottom of the submission form, the request will not be saved and cannot be viewed through the log. Additionally, the log does not include requests called into Clinical Services nor requests submitted through AIM Specialty Health (AIM) and CareCore National, LLC d/b/a evicore healthcare (evicore), independent companies. 6. Why can t I see requests in my Authorization Log that were not submitted through NaviNet? The Authorization Log allows providers to view only those requests submitted through the new Authorizations transaction. Please go to the Authorization inquiry screen to review all requests associated to your organization. For detailed instructions, review the Authorization Submission and Inquiry Guide, which can be found in the NaviNet Resources section of the Independence Provider News Center at 7. Why do I see requests submitted by another group or facility in my Authorization Log? If your provider group or facility is named on a request (e.g., ordering or servicing provider), the request will display on the Authorization Log. 8. Why do I see Cancelled authorization requests in my Authorization Log? The health plan may cancel a request for varying reasons (e.g., duplicate requests submitted for the same member for similar services). Before calling the health plan, please go to the Authorizations inquiry screen to review all requests submitted for a member. 9. Can I cancel an approved authorization request through NaviNet? No, providers cannot cancel requests in NaviNet when the status of the request is approved, pending, or denied. To cancel requests, providers must call Clinical Services at 1-800-ASK-BLUE and select Authorizations from the menu. 10. Can I identify the individual who initiated the authorization request? The Authorization Detail screen provides the contact information of the individual who submitted the request. Additionally, the Authorization Log offers a History link that provides details such as the name of the individuals responsible for submitting or modifying the request. 2 of 4
11. Do I continue to submit requests for services supported by AIM and evicore? Yes, providers should continue to submit requests to AIM and evicore for services supported by their respective organizations. These requests can be submitted by selecting Authorizations from the Independence Workflows menu, and then either AIM or evicore. 12. How do I access the Authorization Census report? Please review the Authorization Census Report Job Aid, which can be found in the NaviNet Resources section of the Independence Provider News Center at 13. Why am I receiving the below red-line error message after entering the Ordering/Admitting physician? Although the selected Ordering/Admitting Physician is participating with the Health Plan, they are not contracted for the Member s specific network. For the following Service Types please use the Manually Entered Provider link to enter your provider information Ambulance-Land, DME, ER Admission, Home Health, Home Infusion, Medical Surgical or Skilled Nursing Facility. For Chemotherapy or Infusion Therapy please search for another Provider or refer to the Network Facility/Provider Inquiry transaction to locate a participating Provider. While the physician may be participating with the health plan in general, they may not be contracted for a specific network. Please follow the instructions provided in the message. 14. What is the expected turnaround time when submitting an authorization request and how will I know if it has been approved? For elective requests, the plan has up to 14 days to respond. However, most requests are responded to within five business days. Phone calls will only be made for Medicare requests; all other decisions will be posted on NaviNet. For emergency admissions, decisions will be made and communicated within 72 hours of receipt of the necessary clinical information. 15. What is our recourse when we do not receive authorization approval by the time we pick up a patient (Ambulance Land)? Be as proactive as possible in initiating requests for ambulance services. Become familiar with the following policies regarding coverage of non-emergent ambulance requests should the transport need to occur before authorization is completed: Commercial: #12.04.02f: Nonemergency Ambulance Transport Services Medicare Advantage: #MA12.002: Nonemergency Ambulance Transport 16. What should I expect to receive for an approval? Commercial approvals can only be found on NaviNet through the Authorization Inquiry transaction; they will not be faxed. Clinical Services will call providers to relay Medicare determinations. Letters will be sent for all denials. 3 of 4
17. Can I call in to expedite requests for emergency/urgent chemo/infusion therapy (such as authorizing drugs)? If the request is for a service within the next two days, you should request an expedited or urgent determination by calling 1-800-ASK-BLUE and selecting Authorizations from the menu. 18. When creating the authorization, should I list the contact as the person entering the authorization or the individual actually working the case? The individual working the case who can provide clinical information would be the preferred contact. 19. Should the Authorizations transaction be used for authorization requests for behavioral health/substance abuse services? (Added 10/24/17) No, behavioral health providers should continue to submit authorization requests through Magellan Healthcare, Inc., an independent company. This process is not affected by the new transaction. 20. When submitting a request for Chemotherapy or Infusion services, are administrative procedures (i.e., 96413, 96416) required? (Added 10/24/17) No, administrative procedures should not be included on the request form when submitting through the Authorizations transaction. This may cause you to receive an error message. 21. Why are my Home Health requests pending for services that were typically approved before the release of the new utilization management system? (Added 10/24/17) When submitting authorization requests for home care services, providers are strongly encouraged to request no more than 28 days of services at a time. Requests submitted for more than 28 days will automatically pend for review, which may delay the determination. 22. Why don t I see the Amend link (where applicable) for all of my prior authorization requests (i.e., Case)? (Added 10/30/17) Only requests submitted through the provider portal (i.e., EXT) offer the Amend link when applicable. If you need to add, extend, or amend a request previously called into the plan, please call Clinical Services at 1-800-ASK-BLUE and select Authorizations from the menu. 23. When submitting an authorization request with procedure codes or services, can my date of service/date of admission value differ from the Service From date? (Added 10/30/17) With the exception of medical pre-admission testing, the date of service/date of admission value located at the top of the submission form should not differ from the Service From date under the section entitled Services and Durable Medical Equipment. These dates should be the same. 4 of 4
SNF-specific questions 24. Can sub-acute requests be submitted via this transaction? Yes, requests can be submitted by the sub-acute facility. 25. How should medical necessity/clinical notes and other necessary documents be submitted? Notes and documents can be faxed as they are today. These documents cannot be sent via NaviNet. 26. How should I complete the survey when I don t have, and can t get, all the answers to the survey questions? For example, Has the patient been in a SNF in the past three months? NaviNet survey questions denoted with an asterisk require a response. While the plan would prefer a response to all questions, those not denoted with an asterisk do not require a response. 27. Do I need to enter a new authorization if a SNF authorization is approved and then the patient is held longer at the hospital, which now changes the SNF admission date? You do not need to enter a new authorization request if the admission date is within seven days of the original date. If beyond then, a new authorization is needed. 28. How are concurrent reviews and extensions on the SNF stay handled? There is no change to these processes. Please continue to initiate through the SNF phone line at 1-866-319-6954. For more information Please refer to the NaviNet Resources section of the Independence Provider News Center at www.ibx.com/pnc/navinet for more information. If you cannot find the information you are looking for here and have further questions, please call our ebusiness Hotline at 215-640-7410. Magellan Healthcare, Inc. manages mental health and substance abuse benefits for most Independence members. NaviNet is a registered trademark of NaviNet, Inc., an independent company. 5 of 4