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Payor Based Authorizations examples - Cal-PM

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These scenarios show how Payor Based Authorization and Managed Care Authorization definitions affect claim file output.

Note: Names and identities in these examples are fictitious. No identification with actual persons (living or deceased), information, or location is intended or should be inferred. 

Scenario: Payor Based Authorization

In this scenario, the Payor Based Authorization definition has the following parameters:

  • Guarantor - Medi-Cal (800)
  • Program - O.P. Adult Psych
  • Effective Date - 7/1/2022
  • Service Code(s) - (1000) Psychiatric Evaluation
  • Authorization Number - 12345PAYORBASEDAUTH 

A service is provided to Susan Matlock using the parameters defined in the Payor Based Authorization.

clipboard_e2d4b0d46a7357c8d1e7f89da6781706f.png

When the 837 is generated, the claim file outputs the Authorization Number configured in Payor Based Authorizations:

CLM*IDX5X1X1*75***11:B:1*Y*A*Y*Y~

DTP*435*D8*20220101~

REF*G1*12345PAYORBASEDAUTH~

REF*EA*IDX5X1~

HI*ABK:F41.9~

NM1*77*2*O.P. ADULT PSYCH.~

N3*2 NASSAU AVE.~

N4*SAN DIEGO*CA*921220000~

LX*1~

SV1*HC:97155*75*UN*1*11**1~

DTP*472*D8*20230104~

REF*G1*12345PAYORBASEDAUTH~

NM1*77*2*O.P. ADULT PSYCH.~

N3*2 NASSAU AVE.~

N4*SAN DIEGO*CA*921220000~

Scenario: Managed Care Authorization and Payor Based Authorization

There may be instances when an organization has a Managed Care Authorization defined for a specific client that conflicts with an existing Payor Based Authorization.

In this scenario, the Authorization Number entered in the Managed Care Authorization is reported in the outbound claim.

The Payor Based Authorization definition has the following parameters:

  • Guarantor - Medi-Cal (800)
  • Program - O.P. Adult Psych
  • Effective Date - 7/1/2022
  • Service Code(s) - (1000) Psychiatric Evaluation
  • Authorization Number - 12345PAYORBASEDAUTH

The Managed Care Authorization definition for Susan Matlock in her O.P. Adult Psych episode that covers services billable to her Medi-Cal guarantor has the following parameters:

  • Guarantor - Medi-Cal (800)
  • Program - O.P. Adult Psych
  • Effective Date - 7/1/2022
  • Service Code(s) - (1000) Psychiatric Evaluation
  • Authorization Start Date - 7/1/2022
  • Authorization End Date - 6/30/2023
  • Type of Authorization - Admission
  • U/R Staff Person - Cathy James 

A service is provided to Susan Matlock that meets the parameters defined in Managed Care Authorization and Payor Based Authorization:

clipboard_e093f6e40de2d3a3da7582509829b4c6a.png

When the 837 is generated, the claim file outputs the Authorization Number configured in Managed Care Authorization:

CLM*IDX5X1X1*75***11:B:1*Y*A*Y*Y~

DTP*435*D8*20220101~

REF*G1*MANAGEDCAREAUTH~

REF*EA*IDX5X1~

HI*ABK:F41.9~

NM1*77*2*O.P. ADULT PSYCH.~

N3*2 NASSAU AVE.~

N4*SAN DIEGO*CA*921220000~

LX*1~

SV1*HC:97155*75*UN*1*11**1~

DTP*472*D8*20230105~

REF*G1*MANAGEDCAREAUTH~

NM1*82*1*JAMES*CATHY****XX*1497474936~

PRV*PE*PXC*101Y00000X~

NM1*77*2*O.P. ADULT PSYCH.~

N3*2 NASSAU AVE.~

N4*SAN DIEGO*CA*921220000~