Post on 31-Mar-2015
HP Provider Relations
February 2011
Prior Authorization
via Web interChange
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Agenda
– Objectives
– Valid provider types
– Demonstration
– Attachments
– Prior authorization (PA) inquiry
– PA status defined
– Helpful tools
– Questions
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Objectives
Following this session, providers will be able to:
– Determine which provider types can submit a PA request via Web interChange
– Complete the PA Submission screen in Web interChange
– Look up PA requests that were previously submitted
– Mail attachments related to a PA request
DescribeValid Provider Types
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Valid Provider Types405 IAC 5-3-10 identifies the provider types that may submit a PA request via hard copy or electronically:
–Doctor of medicine
–Doctor of osteopathy
–Dentist
–Optometrist
–Podiatrist
–Chiropractor
–Psychologist endorsed as a health service provider in psychology (HSPP)
–Home health agency (authorized)
–Hospital
–Transportation provider
–Any provider with prescriptive authority under Indiana law who prescribes drugs subject to PA
DemonstratePrior Authorization
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Certification TypeDemonstration
Listed below are definitions for the options available under "Certification Type":
– Appeal – Immediate• Informs the IHCP the request is for an administrative review
– Appeal – Standard• Informs the IHCP the request is for an administrative review
– Extension - Indicates the request is for an update to a previously approved PA
– Initial - Indicates a new request
– Renewal – Indicates an update to a previously approved PA
– Revised – Indicates a request for a change or update to a previously approved PA
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Prior Authorization via Web interChange
Type up to 264 characters
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Submitting the PADemonstration
– After submitting the PA, a pop-up window will display the member name and a Confirmation Number
– Web interChange will generate the PA number within 30 minutes after submitting the PA
– Until the PA number is generated, use the Confirmation Number to view the PA using the PA Inquiry function
ExplainAttachments
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Attachments
– Most PA requests require documentation to support medical necessity• Exception: Non-emergency transportation services
– To send required documentation for PA requests submitted via Web interChange, print the Prior Authorization System Update Request Form• The form is available under the Forms link at www.indianamedicaid.com
• Include the PA number – the PA number alerts CME staff that the documentation is related to a PA that has already been submitted and is in an Evaluation or Suspended status
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Attachments
CreateEnter PA #
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Attachments
– Fax the Prior Authorization System Update Request Form and supporting documentation to ADVANTAGE Health Solutions for
Traditional Medicaid Fee-for-Service and ADVANTAGE Care Select:
FAX: 800-689-2759
– Fax the Prior Authorization System Update Request Form and supporting documentation to MDwise Care Select:
FAX: 877-822-7186
DescribePrior Authorization Inquiry
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Prior Authorization Inquiry
DefinePA Status
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PA Status – Defined
Following are some of the statuses commonly assigned to PA requests:
–Approved – medical necessity guidelines are met
–Suspended – additional information requested from the member and/or the provider
–Modified – the request is approved; however, the approval is not in accordance to the requested dates, units, or dollar amount found on the original request
–Denied – the request is not approved
–Rejected – the request could not be processed
–Evaluation – request is awaiting a decision
–No PA required – procedure/revenue code does not require PA
Find HelpResources Available
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Helpful Tools
– IHCP Web site at www.indianamedicaid.com
– IHCP Provider Manual, Chapter 6
– ADVANTAGE Health Solutions – Care Select• Telephone: 1-800-784-3981
– MDwise – Care Select• Telephone: 1-866-440-2449
– ADVANTAGE Health Solutions – Fee For Service• Telephone: 1-800-269-5720
– Provider field consultant • http://provider.indianamedicaid.com/contact-us/provider-
relations-field-consultants.aspx
Q&A