Prior Authorization
via Web interChange
HP Provider Relations
February 2011
Agenda
– Objectives
– Valid provider types
– Demonstration
– Attachments
– Prior authorization (PA) inquiry
– PA status defined
– Helpful tools
– Questions
2
Prior Authorization via Web interChange
February 2011
Objectives
Following this session, providers will be able to:
– Determine which provider types can submit a PA request via Web
interChange
– Complete the PA Submission screen in Web interChange
– Look up PA requests that were previously submitted
– Mail attachments related to a PA request
3
Prior Authorization via Web interChange
February 2011
Describe
Valid Provider Types
Valid Provider Types
405 IAC 5-3-10 identifies the provider types that may submit a PA request
via hard copy or electronically:
– Doctor of medicine
– Doctor of osteopathy
– Dentist
– Optometrist
– Podiatrist
– Chiropractor
– Psychologist endorsed as a health service provider in psychology (HSPP)
– Home health agency (authorized)
– Hospital
– Transportation provider
– Any provider with prescriptive authority under Indiana law who prescribes
drugs subject to PA
5
Prior Authorization via Web interChange
February 2011
Demonstrate
Prior Authorization
Prior Authorization via Web interChange
7
Prior Authorization via Web interChange
February 2011
Prior Authorization via Web interChange
8
Prior Authorization via Web interChange
February 2011
Demonstration
Certification Type
Listed below are definitions for the options available under "Certification
Type":
– Appeal – Immediate
• Informs the IHCP the request is for an administrative review
– Appeal – Standard
• Informs the IHCP the request is for an administrative review
– Extension - Indicates the request is for an update to a previously
approved PA
– Initial - Indicates a new request
– Renewal – Indicates an update to a previously approved PA
– Revised – Indicates a request for a change or update to a previously
approved PA
9
Prior Authorization via Web interChange
February 2011
Prior Authorization via Web interChange
10
Prior Authorization via Web interChange
February 2011
Prior Authorization via Web interChange
11
Prior Authorization via Web interChange
February 2011
Prior Authorization via Web interChange
12
Prior Authorization via Web interChange
February 2011
Prior Authorization via Web interChange
Type up to 264 characters
13
Prior Authorization via Web interChange
February 2011
Prior Authorization via Web interChange
14
Prior Authorization via Web interChange
February 2011
Demonstration
Submitting the PA
– After submitting the PA, a pop-up window will display the member name
and a Confirmation Number
– Web interChange will generate the PA number within 30 minutes after
submitting the PA
– Until the PA number is generated, use the Confirmation Number to view
the PA using the PA Inquiry function
15
Prior Authorization via Web interChange
February 2011
Explain
Attachments
Attachments
– Most PA requests require documentation to support medical necessity
• Exception: Non-emergency transportation services
– To send required documentation for PA requests submitted via Web
interChange, print the Prior Authorization System Update Request Form
• The form is available under the Forms link at www.indianamedicaid.com
• Include the PA number – the PA number alerts CME staff that the documentation is
related to a PA that has already been submitted and is in an Evaluation or Suspended
status
17
Prior Authorization via Web interChange
February 2011
Attachments
Enter PA #
18
Prior Authorization via Web interChange
Create
February 2011
Attachments
– Fax the Prior Authorization System Update Request Form and
supporting documentation to ADVANTAGE Health Solutions for
Traditional Medicaid Fee-for-Service and ADVANTAGE Care
Select:
FAX: 800-689-2759
– Fax the Prior Authorization System Update Request Form and
supporting documentation to MDwise Care Select:
FAX: 877-822-7186
19
Prior Authorization via Web interChange
February 2011
Describe
Prior Authorization Inquiry
Prior Authorization Inquiry
21
Prior Authorization via Web interChange
February 2011
Prior Authorization Inquiry
22
Prior Authorization via Web interChange
February 2011
Define
PA Status
PA Status – Defined
Following are some of the statuses commonly assigned to PA
requests:
– Approved – medical necessity guidelines are met
– Suspended – additional information requested from the member
and/or the provider
– Modified – the request is approved; however, the approval is not
in accordance to the requested dates, units, or dollar amount
found on the original request
– Denied – the request is not approved
– Rejected – the request could not be processed
– Evaluation – request is awaiting a decision
– No PA required – procedure/revenue code does not require PA
24
Prior Authorization via Web interChange
February 2011
Find Help
Resources Available
Helpful Tools
– IHCP Web site at www.indianamedicaid.com
– IHCP Provider Manual, Chapter 6
– ADVANTAGE Health Solutions – Care Select
•
Telephone: 1-800-784-3981
– MDwise – Care Select
•
Telephone: 1-866-440-2449
– ADVANTAGE Health Solutions – Fee For
Service
•
Telephone: 1-800-269-5720
– Provider field consultant
•
26
http://provider.indianamedicaid.com/contact-us/providerrelations-field-consultants.aspx
Prior Authorization via Web interChange
February 2011
Q&A