service, e.g. type of provider, site of care, etc. Identify if/what supporting documentation that needs to be sent with a review request, including documentation for Unlisted Procedures Supporting documentation requirements are not identified on the site. Identify clinical criteria Met Medical policies are difficult to find unless you are an experienced user. (They are under Tools and Resources rather than Clinician Resources) See website#10 comment Identify whether approval of this service is dependent upon previously trying other services, i.e. “tried and failed”. Submitting Review Request Steps – Many providers don’t initiate the submission process unless clinical documentation is complete and available to administrative Otherwise there is a risk of denial if the clinicals can’t be faxed in two days. Select ‘Radiology Notification …’ entries in ‘Notifications/ Prior Authorizations’ drop down Enter required information into UHC site Provide an online form/web page for requesting pre-service review Met On form/web page - Allow specification of the “urgency” of the request Services requiring an urgent review can’t be requested online. There is a highlighted note on the request page that indicates that UHC needs to be called for urgent requests. Identify the time frame under which the request will be reviewed, somewhere in the process On form/web page - Allow specification of ALL the services/medication/administration to be reviewed Met A separate request needs to be submitted for each CPT code. See website #8b comment. On form/web page - Include questions about any relevant There are no site of service restrictions on any imaging services
In cases of clinical questions, try to select the best answer based upon the information contained in the clinical notes, If auto-approved, enter the auth number and date of service ranges into the EHR, and/or take a screen authorization professional restrictions (as applicable) N.A. If form/web page asks for clinical information, either offer check list selection of appropriate clinical information or allow provider to submit ALL clinical information relevant to the specific request for services, and not restrict provider from sending this relevant information Met Site provides a very long, small-font list of possible answers from which to choose. See website #8f comment. for submission of form electronically or faxed with supporting documentation Met Some supporting information can be cut and pasted into the request form. Up to a single 5 MB word document can be uploaded Uploaded and faxed documents are not always “received’ by UHC. Provide an acknowledgement receipt of the review request Met Either an authorization number (if auto-approved) or a case number Able to print the completed request form and/or review online the information submitted on the request. Perform review for ALL submitted services that are valid per the BPR, not just those requiring a -- including Unlisted Procedures, except for those listed on health plan website. For a number of Unlisted Procedures, the site will not confirm the description for the CPT code. A call to UHC must be made to make the request. Perform review without a provider signature on the request Met
shot of the information. If not auto-approved, put the case number into the EHR. Upload or fax supporting documentation. (However may still get a call from UHC reviewing nurse asking for clinicals) On web page, identify how changes are to be made to previous requests and how providers will be notified of decisions Checking Status of Request Steps Check Status which is available once the ‘Radiology Notification and Authorization …’ entry in the ‘Notifications/ Prior Authorizations’ drop down list is selected. If pre-auth request was not auto approved within two days after submission, check status on website to see if a letter has been posted about required documentation. If not, call. Provide status information on website per the BPR Identify any information that is missing. Reporting Statuses are Approved, Pending, Denied. A letter is sometimes included that indicates what additional information is needed. Pending status does not always have a letter attached, in which case there is no information about whether action is required of the provider and/or if what documentation is required Allow access to status information by the provider/organization that requested the services, the provider/organization that is doing the services and, as appropriate, the facility/organization where the services are to be done Met Can see status of pre-authorizations that were requested by outside providers.