authorization & refferals

In Neetisha Medical infotech we are experts in referrals and authorization process management. We have gone through all the issues associated with referrals authorizations. We have three phase processes with expert workforce in place to manage your referrals and authorization requirements.

1. Referral Management :

2. Authorization Management :

  • Prescription Drug authorization
  • Medical Drug/Other authorization
  • Radiology Authorization

Benefits :

  • Referrals management we have dedicated work force for management of referrals INCOMMING or OUTGOING referrals.
  • In Referrals/Authorization Management we understand the value of time and our team is committed to provide you accurate and timely authorizations in all different segments. We also make sure that we follow all the pending referrals/authorizations on timely manner and make sure that your cash flow must increase.
  • In Prescription Drugs authorization we fill our all the required forms as per the insurance plan and check the drug formulary as per the insurance. We will make sure that all your patients get their prescription filled on time.
  • In Medical Drugs or procedures authorizations we have a dedicated team that will follow all the claims and will track the authorization requirement as per the plan benefits.
  • Radiology Authorization like: CT SCAN, MRI, PET SCAN are also done in timely manner we use web sites and insurance calling to get the authorizations done.
  • We communicate with patients about authorizations and help them to fix the appointments with rendering facility..
  • The referral and authorization process per insurance plan is complex and labor intensive for the providers. In Neetisha Medical Infotech we manage each plan’s unique requirements for the providers. We have system in place to manage multiple insurance plans with variety of benefits and streamlined the process in a cost effective manner.
  • We manage all your managed care transactions that require enormous amount of paperwork, especially when the referral requests and authorizations never catch up to the claims submitted for the already provided services. This results in a delay in payment to the provider and resubmitted claims as well as phone calls to the plan to resolve the problem.

Authorization system :

Authorization system has to determine who has the authority to authorize services. This is dependent on the plan and the degree it will medically managed the services provided. For optimal control, the PCP authorizes services for their patients, except for those expensive services that require the plan’s medical director. So if a referring specialist wants to schedule additional tests or procedures, they must go through the PCP “gatekeeper” first. This requires the use of unique authorization numbers that tie to specific bills, and the claims department must be able to back up with documentation. As a result, if an authorization number is not associated with a claim, then payment can be denied by the plan due to not having prior authorization. The plan must develop and communicate their policies and procedures for defining what services require authorization and which ones do not.

Types of authorizations :

  • Prospective or precertification is issued before any service is rendered. This allows for the greatest control to direct care to the most appropriate setting and provider.
  • Concurrent authorization is rendered at the time the service is rendered. Does not allow for the plan to determine if services need rendered, but it does allow for timely data collection and the ability to impact the outcome.
  • Retrospective authorization takes place after the services are rendered. These authorizations are usually issued for “emergency situation”, such as an automobile accident requiring immediate care and hospitalization.
  • Pended (for review) authorization is for those cases that it needs to be determined if an authorization was issued or will be issued. The case must have a medical review to determine:
    • Medical necessity
    • Eligibility (Is the service covered?)
    • Administrative review
  • Denial means there will not be an authorization for services.

The data elements commonly captured for authorizations are listed below :

  • Member’s name
  • Member’s birth date
  • Member’s plan identification number
  • Eligibility status
    • Commercial group number or public sector (i.e., Medicare & Medicaid) group identifier
    • Line of business (e.g., HMO, POS, medicare, medicaid, conversion, private, self-pay)
    • Benefits code for particular service (e.g., noncovered, partial coverage, limited benefit, full coverage)
  • PCP
  • Referral provider’s name and specialty
  • Outpatient data elements
    • Referral or service date
    • Diagnosis (ICD-9-CM)
    • Number of visits authorized
    • Specific procedures authorized (CPT-4)

Since every authorization number must be unique, the authorization system must be able to generate and link the number to the specific data for which the number was issued. A claim must include the authorization number in order to be processed for payment.

There are three main methods for communicating with a plan’s authorization system :

  • Paper-Based Authorization Systems require the provider to fill out pre-printed forms per referral request and submit by mail to the health plan. Process is labor intensive and each plan has own set of required forms that the PCP staff must keep straight.
  • Telephone-Based Authorization Systems require the PCP or office staff to call a central number and give the required information over the phone for an authorization. This system is known for its problems of busy signals for long lengths of time, being placed on hold for long periods of time and tying up office and hospital staff time. This system often is used in conjunction with a fax machine to receive authorization forms and to supply the MCO with further clinical data (office notes, previous test results, expanded diagnosis list). It is not productive and can waste precious time.
  • Electronic Authorization Systems require the participating providers and hospitals to connect electronically to the health plan. Today, this is usually through a dumb terminal or a computer in the office.