Service Authorization

Main Details

1. Click Brief Member Review to generate the Brief Member Review Report, that details the member's diagnosis and treatment information.
   • Treatment information details services contained in EOBs in the last 180 days.
2. Click Member Authorization History to generate the Member Authorization History report, that details the member's previous service authorizations.
3. In the Type of Authorization field, select the authorization type.
   • The Authorization Number field displays the service authorization number.
4. In the Funding Source Authorization Is For field, select the funding source.
   • Funding sources associated with the member are available (Member Enrollment form).
   • If the Require Member Enrollment registry setting is set to 'N', all registered myAvatar MSO funding sources can be selected.
5. In the Provider To Be Authorized field, enter the provider name, and select.
   • Providers associated with the funding source are available in the Contracting Provider Registration form.
   • Providers can be associated to multiple funding source if the Require Funding Source registry setting is enabled.
6. In the Performing Provider field, select the facility member.
7. In the Performing Provider Type field, select the provider type.
   • Performing provider types are defined in the Contracting Provider Registration form.
8. In the Planned Admit Date field, enter the planned admission date.
9. In the Authorized Level of Care field, select the level of care.
10. In the Current Authorization Status field, select Approved if this authorization has been approved.
11. In the Current Authorization Status Reason field, select the authorization status reason.
12. In the Account field, select the budget tracking account.
    • Setup in the Budget Tracking Account Setup form.
13. In the Initial or Continuing Authorization field, select Initial if this is the member's first authorization.
    • Select Continuing for an additional member authorization.
    • Select Copy to copy information from an existing authorization to the current authorization.
    • If Copy is selected, the Authorization Listing screen displays. Select the service authorization and click OK.
    • The Begin Date of Authorization field will default to the current date, and the End Date of Authorization will be set such that the authorization is for the same length of time as the original.

Dates 

1. In the Begin Date of Authorization field, enter the authorization begin date.
2. In the End Date of Authorization field, enter the authorization end date.
3. In the Next Review Date field, enter the authorization next review date.

Authorization Details

1. In the Prevent Approved Services From Pushing To Parent System field, select Yes to stop services associated to the authorization from being pushed to parent myAvatar PM system on claims processing batch closing (regardless of other conditions for services to be pushed).
2. In the Contracting Provider Authorization field, select the contracting provider service authorization to link to this authorization. This is used to limit the total estimated liability. Unit limitations will apply.
   • This display of this field is determined by the selections made in the Provider To Be Authorized, Begin Date Of Authorization, and End Date Of Authorization fields.
   • This field will be disabled if no authorizations match the criteria, or if the Funding Source Authorization Is For field has Contracting Provider Service Authorizations Contain Dollar Limitations set to No.
3. In the Authorization Grouping or Individual Authorizations field:
   • Select Grouping to select a Service Authorization Group.
   • In the Authorization Grouping field, select the authorization grouping.
   • Select Individual to select an individual service.
   • Select All to authorize all CPT procedure codes and revenue codes.
4. Click Display Authorization Grouping to generate the Authorization Grouping Definition report, which details authorization grouping information.
5. The Total Estimated Liability field displays the total liability codes, for the authorized service codes.
6. In the Letter Type field, select the letter type.
7. In the Procedure Code Type fields, select CPT Code for CPT code services. Select Revenue Code for revenue code services.
8. In the Begin Date of Service field, enter the authorization begin date.
   • Services claimed before this date are denied.
9. In the End Date of Service field, enter the authorization end date.
   • Services claimed after this date are denied.
10. In the Code Authorized fields, enter the CPT or revenue code, and select.
11. In the Units Authorized fields, enter the number of units authorized.
    • These fields are enabled when Yes is selected in the Member Authorizations Contain Unit Limitations field (Funding Source Registration form).
    • If an authorization has claimed services against it, the procedure code for associated services cannot be edited or deleted.
12. In the Contracting Provider Authorization field, select the provider.
13. In the Inhibit Adjudication For Services Claimed During Authorization Period field, select the type of authorization that will not be claimed.
14. In the Claim Status for Inhibited Services field, select the claim status to apply when a service is pended or denied, according to the authorization inhibit settings.
15. In the Claim Status Reason for Inhibited Services field, select the claim status reason to apply when a service is pended or denied, according to the authorization inhibit settings.
16. In the Exclude Procedure Code Group Definition field:
    • Select procedure code groups to be excluded from adjudication inhibition.
    • If adjudication is being inhibited for certain authorizations, selecting procedure code groups will allow services using one of the selected CPT or revenue codes to be adjudicated.
17. In the Exclude Revenue Code field:
    • Select revenue codes to be excluded from adjudication inhibition.
    • If adjudication is being inhibited for certain authorizations, selecting revenue codes will allow services using one of the selected codes to be adjudicated.
18. In the Exclude CPT Service Code field:
    • Select CPT codes to be excluded from adjudication inhibition.
    • If adjudication is being inhibited for certain authorizations, selecting CPT codes will allow services using one of the codes to be adjudicated.
19. When finished, click Submit.

Additional Sections

• Care Manager

• Diagnosis

• Comments

• Provider Search

► SQL Tables

• SYSTEM.service_auth_detail
• SYSTEM.service_auth_svc

► Registry Settings

• Allow Member Service Authorizations Without Contracting Provider
• Default Funding Source Authorization Based On Admission Program
• Display Associated Case/Population Field
• Display Registration Dates with Performing Provider's Name
• Display Requested Units Fields
• Eligibility Check Warning
• Enable 270/271 Submission on Service Authorization
• Enable 837 Encounter From PM
• Enable Admission Date Range Warning
• Enable Authorization Frequencies
• Enable Budget Tracking
• Enable Copy Authorization
• Enable Contracting Provider Program
• Enable Cross Funding Source Member Level Service Authorizations
• Enable Default Begin/End Date Of Service
• Enable Effective Date
• Enable Eligibility Check
• Enable Estimated Liability Code Fields
• Enable Group Service Begin/End Date
• Enable Individual Service Begin/End Date
• Enable Service Authorization by Plan
• Message Type For No Code/No Units
• Require Diagnosis Entry
• Restrict Code Authorized by Provider
• Security Level Required To Delete Member Enrollment From Pre Display
• Security Level Required To Delete Service Authorization From Pre Display
• Set Service Authorization Pre Display