Authorizations

If adding a STAT or same day/next day insurance, you must allow a 4-hour gap to obtain authorization

STAT/Double bookings: ONLY SUPERVISORS/LEADS CAN DOUBLEBOOK

If patient has a Medicaid/State Funded insurance plan, they cannot be offered self-pay as another option.

Auth requirements:

Health Choice/Health Choice Generations: OB US is 5-7 days TAT, DUPLEX/DOPPLER is 5-7 day minimum TAT

Tricare: All US, MG, BD, MRI & CT require auth- 14 days minimum TAT

Alignment: US- 7 days minimum TAT

Optum: MRI, NM, PET, CTA, MRA is 14 days minimum TAT (In Nevada ONLY: Out of network for all PET, NM & US except ABI, Arterial, Venous mapping and Prostate and out of network for ALL CT except CT lung, CTA for PE, CTA runoff and patients over 400 lbs.  

Mercy Care/Mercy Care Advantage: US (Elastrography) cpt 76981 is a 14 day minimum TAT

Scan Health: ALL Breast Imaging - 7 day minimum TAT

 Humana: All CT/A, MRI/A, NM Modalities are 5-7 days.

Humana FL (Only) All modalities - Schedule 9 days out.  Add-Ons ONLY allowed if patient has referral/authorization number on hand.

COMMONLY MISCHEDULED PROCEDURES

MEDICARE INSURANCE ALERTS:

There have been some changes made in our Medicare Insurance Alerts.

What are the changes?

We have added information on which exams require the patient to sign an ABN.

When scheduling Medicare patients we will need to look at the alerts and see if an ABN may be required at TOS.

If so we will need to let the patient as a heads up so they are aware.  

Please see example of alert below.

We have recently updated the rates for many of our Self-Pay Company Accounts.  Majority of AZ has been updated making many inactive. This is now on the Operations, Contact Center and Sales page on the Simonmed portal.  See screenshot below.  There is a link for each to view the price sheet.  Good Visit will be updated with the pricing.

AUTHORIZATION CALL HANDLING

If you receive calls regarding Authorization for a procedure we cannot transfer to any Authorization Queues, as the call will be routed back to the General Scheduling Queues.

Like with any call we receive we should identify what the need is of the caller and resolve. Below are some very common scenarios for Authorization Call Types

1.       Is my exam approved?

Agent will look up patient, find the scheduled exam and open accession. From there go to notes and choose schedule notes.

Verbiage to look for in regards to authorization notes:

Approved

Requested/Awaiting Clinical from MD

Pending Med Review (Awaiting for insurances answer)

Denied Fax MDO Awaiting Peer to Peer (ordering MD calls into insurance to try and obtain approval)

Infinx Initiated

1.       What if notes state pending authorization?

Let patient know since their exam has not been authorized they will need to be rescheduled, then transfer to the scheduling queue if you are an Operator

Rescheduling time Frames should be noted

If not use the below

Note states “pending payor approval” 3-5 business days,

Note states “pending clinical” 5-7 business days

2.       What if there are no notes about authorization and that is what the caller is inquiring about?

Notate the accession and then send a follow up email for validation (EMAIL TEMPLATE ATTACHED), SEE DETAILS BELOW.

3.       What do we do when a caller says they have approval but notes say different?

Please ask for the authorization number or a  number to reference if caller was given one, notate the accession and then send a follow up email for validation (email template attached), details below.

You can make the caller aware that we will check on the information they have shared and will reach back around to them if any follow up is needed.

4.       What do we do if its pending and it’s a STAT order?

Please follow the reschedule guidelines above, STAT or not. This means that although we attempted to obtain the authorization in a STAT manner for their appointment it still is not ready and we need to reschedule to allow for that.