ONH REG Authorization Training

onh registration

Authorization Training

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Be honest...How much do you actually know?

What Are We Even Doing Here?

What is an Authorization? Authorization= approval from the insurance company before services are done to confirm:

• Medical necessity
• Coverage eligibility
• Payment likelihood

Why Is It Important?

How Long Do You Really Have?

Authorization Timeframe

• Authorizations must be completed within 24-48 hours

• If authorization cannot be completed on the weekend due to payor portal being down or Insurance company is closed, the 24–48-hour clock beings that following business day (Monday). Document attempt in patient chart!

Okay.. So what insurances require authorizations?

Most commercial insurance plans require prior authorization. Always verify coverage and authorization requirements! TRICARE Standard (PPO) Most services do not require authorization Inpatient (IP) services do require authorization For Outpatient (OP) services, verify on the TRICARE website to confirm whether authorization is needed. TRICARE Prime (HMO) Authorization is most likely required for all services rendered CHAMPVA Authorization is only required for: Cosmetic services Experimental procedures Transplant services VA Coverage VA notification on website

Medicaid

Medicare Traditional No authorization required for IP / OP / Ambulatory Surgery / OBS Exception: Authorization may be required if the service is considered cosmetic or experimental Medicare Advantage Plans Authorization is required for IP / OP / OBS Always submit the request and allow the payer to determine if authorization is not required. Do not assume. Medicaid MMA Plans / Full Medicaid / Medicaid SOC No authorization required ONLY if Medicaid is secondary to Medicare or a Medicare Replacement plan

Okay team… quick pop quiz !

Pre-Certification Status

• Clinicals Requested (Observation/Inpatient)- Pending Authorizations

• Approved (Observation/Inpatient)- Approved Authorizations

• Denied (Observation/Inpatient)- Denied Authorizations

• Not Needed (Observation/Inpatient)- Not Required

• We do not complete Ambulatory Surgery authorizations! Change status to Clinicals Requested (Ambulatory Surgery)

• Medicaid Florida authorization request goes through the UM team in Gainesville. Change status to clinicals requested (Observation/Inpatient)

If a patient’s status changes from observation to inpatient, a new authorization must be obtained to reflect the updated level of care!

Questions or Concerns?