Contracting Provider Service Authorization

Authorize services to be performed by a contracting provider, for any member. Service authorizations are used in claim processing forms, and the Fast Service Entry form.

• Services must be associated with a service authorization in order to be reimbursed.
• Service authorizations can be edited in the Service Authorization (Unlimited Codes) form.
• Service authorizations created in the Service Authorization (Unlimited Codes) form are display only in this form.
• Editing a field that alters service availability can be adjudicated through the Manual Batch Adjudication form (open batches), and Retro Claim Adjudication form (closed batches).

Note: When an authorization is edited, certain procedure codes may be disabled if services have been claimed against it.

Prerequisites:

• The provider must be associated with a funding source in the Contracting Provider Registration form.

1. Go to: Avatar MSO > Care Management > Contracting Provider Service Authorization
2. In the Select Provider screen, search for and select the provider by name or ID.
3. Click Brief Contracting Provider Review to generate the Brief Contracting Provider Review report, that details contracting provider demographic information and registration history.
4. In the Type of Authorization field, select the authorization type.
5. The Authorization Number field displays the service authorization number.
6. In the Funding Source Authorization is For field, select the funding source.
7. The Benefit Plan field displays the assigned plan.
8. In the Provider To Be Authorized field, enter the provider name, and select.
9. In the Performing Provider field, select the facility member.
   • If the performing provider associated with the service is different then the provider on the service authorization, the service will be denied authorization.
10. In the Current Authorization Status Reason field, select the authorization status reason.
11. In the Initial or Continuing Authorization field:

    • Select Initial for the first authorization for this member.

    • Select Continuing for an additional authorization for the member.

    • Select Copy to copy the information from another authorization to the current authorization.
      Result: The Authorization Listing screen displays.

    • Select the service authorization, click Ok.
      Result: The new authorization end date populates the Begin Date of Authorization field. The end date is calculated so that the total number of days of the new authorization is equal the copied authorization.

12. In the Begin Date of Authorization field, enter the authorization begin date.
13. In the End Date of Authorization field, enter the authorization end date.
14. 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).
15. In the Next Review Date field, enter the authorization next review date.
16. In the Authorization Grouping or Individual Authorizations field:
    • Select Grouping to select a Service Authorization Group.
    • Select Individual to select an individual service.
    • Select All to authorize all CPT procedure codes and revenue codes.
17. In the Authorization Grouping field, select the authorization group.
18. Click Display Authorization Grouping to display the Authorization Grouping Definition report, which details authorization grouping information.
19. The Total Estimated Liability displays the total estimated liability for the authorized service codes.
20. In the Letter Type field, select the letter type.
21. In the Procedure Code Type fields, select CPT Code if the service procedure is a CPT code. Select Revenue Code if the service procedure is a revenue code.
22. In the Code Authorized fields, select the service procedure. The list of codes are edited and maintained in the respective CPT Code or Revenue Code Definition forms.
23. In the 'Units Authorized' fields, enter the number of authorized units.
    Note: These fields are enabled when Yes is selected in the Member Authorizations Contain Unit Limitations field (Funding Source Registration form).
24. In the Estimated Liability Code fields, the estimated liability is calculated by multiplying the number of authorized units authorized by the service cost.

► Additional Sections

• Diagnosis
• Comments

► Registry Settings

• Enable Effective Date

► SQL Tables

• SYSTEM.service_auth_detail
• SYSTEM.service_auth_svc