Providers: effective July 18, 2021, there was a new Authorization Process for High-Tech & Cardiac Imaging implemented on our authorization tool. To ensure you maximize the benefits of this new tool, we've outlined some tips below to reduce your administrative burden and speed up authorization approvals.
- Select the appropriate requested service
When you are using the prior authorization tool, confirm that you are selecting the proper service—and not choosing the default of other medical. Indicating an accurate service that corresponds with your request only speeds up the process.
- Submit your prior authorization requests on the in-network portal
All contracted providers should be submitting their requests via the in-network portal—not the out-of-network portal. If you’re in-network, you should only be using this portal.
- Provide all supporting clinical documentation.
Be sure that you supply all of the supporting clinical documentation for your request if your request is not automatically approved. ; this gives our clinical team the necessary information needed to review your request.
- Offer the best contact information available
If our clinical team needs more information, they must be able to reach you. If there are multiple outreach attempts without a response, this can initiate a denial. Direct communication is the best way to keep things moving forward. To avoid stalling the approval process, provide the most reachable number, which in some cases, may not be your main office number.
- Mark the request as urgent only if it meets urgency criteria
When submitting a request, consider the variance between urgent vs. non-urgent authorization. For example, an urgent request applies for a patient that needs scans the same day or the next day. Indicating urgency on a request that doesn’t meet urgency criteria slows down the process; this also inflicts inconsistency within the urgent request group.
Additional guidelines to keep in mind:
- If criteria are not met, and clinical information submitted is lacking or insufficient, the Customer Service Team or UMCM (Utilization Management Case Manager) will reach out to the requesting provider. At that time, the provider can speak with our Customer Service Team or UMCM.
- When a patient is rescheduled to a new facility, you cannot change the facility if the request has already been submitted. In this case, a new prior authorization request needs to be submitted via our provider portal—with a note to close out the previous authorization.
- If a determination has been made and the request is still in “med review” status, providers can enter the upcode/downcode via the provider portal using the revision process. The provider must make a notation in the remarks section with a request for an upcode/downcode.
- If the case has been approved and/or denied, a new authorization request will need to be submitted for upcodes/downcodes.