PRIOR AUTHORIZATION
-determine if the request is prior from the surgery or any operations
-if after the surgery,high chances to denied
-"ask when will be the operation"
-document stating that it is medically necessary

Handled by UHC:
-Authorizations and Gap Exceptions for dental, vision, hearing, behavioral health, transplant, experimental treatments, and prescriptions are handled by UnitedHealthcare and follow standard UHC processes.

Terminology	
*Authorization-Decision by a health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary.

*Gap Exception-Request to honor a member's in-network benefits, even though they are seeing an out of network provider. 

*Pre- Determination-Request for a service that does not require a prior authorization, but the provider may want something in writing to confirm coverage for a particular benefit or service.(PROOF ONLY)

125447601

To check for the Referral and autorization(
-go to referrals/authorizations
-click either prior auth or referrals

For Prior Authorization
-access ICUE
-type 7 then Go
-use this to locate the account and from what specific department the member came from
-if found that it came form other department,connect them over since it is a misdirected call(932092740)


if under IFP
-go to History
-you can see the authorization even if it is not stated in Maestro
-if denied then File an Appeal(go to Clinical Escalation-TAT 1 business day from the receipt of referral)

REQUEST PRIOR AUTHORIZATION OR GAP EXCEPTION

-if it is located in the provider list then it needs prior authorization

IF NEEDS PRIOR AUTHORIZATION:
-I'm able to get the process started for you, but to continue I will need to reach out to your doctor to gather some required information. This is the information we need; do you have any of the following?

-Provider name

-Provider telephone number

-Procedure code

-Diagnosis

-Place of service information (Provider name, address, phone number)


If you DID NOT SPEAK with the providers officce then advice the member that you cannot move forward with the request.The provider will need to iitiate a medical authorization through the provider portal

If ABLE TO SPEAK with the Providers office:

-Now that we have all the required information, our next step is to reach out to our provider escalation team to complete the process. Once I have them on the line and have provided them with the required information, I will drop from the call to allow them to finish the call with you.

Is there anything else you would like to discuss before I get them on the line?

WARM TRANSFER TO THE PROVIDERS OFFICE BUT PROVIDE FORST THE NUMBER OF THE PROVIDERS OFFICE INCASE IT WILL BE DISCONNECTED

For Radology/Cardiology- transfer to Evicore 866-889-8054
All others- Provider Services 888-478-4760

ADVISE Provider Services.

My name is <your first name>, and I’m calling to initiate a prior authorization request on behalf of the member. I have all the required information from the member and provider to share with you. Also, I have the member on my other line to transfer to you to complete the call. Can we get started?

Note: if keep on declining,advise the representatie in providers side to check the SOP

 -It is really IMPORTANT and needs the informations to be complete so that validation will go through and the providers office will accept the transfer call.





Request Gap Exception
-must be processed before member seeing the out of network specialist
-if the claim was denied then file a an appeal
-Gap exception is a one time request but if the emmber wanted to continue to be taken care by the OON then they will be requesting another gap request
-If the PCP is the OON, refer to Continuity of Care for 



STEPS
1.offer first an In network
2.able to locate a provider?

Note: This request can be submitted by ANY in-network provider by contacting UHC Provider Services(PCP). When requesting a Gap Exception, providers should submit:

Out of Network Provider Name, Phone number, Address, Tax ID and NPI number.
Procedure code(s)
Diagnosis
POS
Units

If member like you to contact the provider for more explanations, it cannot be done ONLINE.Contact the INN provider and advise about the Gap Exceptions and also provide the OON providers Phone number  Provider Services 1-888-478-4760.

If the surgeon is INN but the facility is not then ask the surgeon to process the Gap Exception.

IT IS VERY IMPORTANT TO PROVIDE TURN AROUND TIME.

ACTIVE COURSE OF TREATMENT
-regular service or care so it will not be worsen

CONTINUITY OF CARE
-Gives UnitedHealthcare members the option to request extended care from their current health care professional if they are no longer working with their health plan and is now considered out-of-network.

NETWORK
-The facilities, providers and suppliers the health plan has contracted with to provide health care services.

OUT OF NETWORK
-Services provided by a non-participating provider.

PRE AUTHORIZATION
-An assessment for coverage under the health plan before the members can get access to medicine or services.

TRANSITION CARE
-gives newly enrolled members (including those switching from another UHC plan) the option to request extended coverage from their current Out-of-Network (OON) healthcare provider for a limited time due to a specific medical condition, until the safe transfer to a network healthcare provider can be arranged.
      For example, member has doctor for a very long time but since tehy have another plan and still they wanted that doctor be assigned unto them


**************************************
Transition of Care (TOC)	
- a transition period based on standard TOC/COC requirements.
-request can be submitted by mail,phone or fax
-must be received within 30 days from a member effective
-If approved, transition to a contracted provider will be required at 90 days, or earlier if the care has been completed or transitioned to a participating provider.

Continuity of Care (COC)	
-Up to 90 calendar days only
-If the doctor that handles them will be switching into OON then member can still visit that doctor up to 90 days but within 90 days the member shoukd be looking for a new INN provider.


REQUIREMENTS
-member must be under active treatment
-The doctor who handles the member will no longer be handling after 90 days if they transition to OON

Examples of medical conditions that may qualify for COC/TOC	
-ongoing transplant recipients needs ongoing care
-pregnancy(trimester)
-Newborn
-Cancer
-Major Surgeries
-Serious Chronic Conditions

Examples of conditions that do NOT qualify for COC/TOC	
-vaccinations
-chronic conditions,diabetes,arthritis,allergies,asthma,kidney
-minor illnesses like colds,sore throats, and ear infections
-elective scheduled surgeries


PROCESS
-fastest and quickest wway a member can have the request reviewed is by contacting the OON
-Completions and submission of the request cannot be guaranteed that it is approved
-Submit request of TOC and COC to the OON
-The application is only for medical services not applicable to Pharmacy

 
Application for North Carolina - TOC COC form NC: The application must be completed within 45 days of the plan’s effective date or within 45 days of the care provider’s termination date.

Members can mail or fax the completed applications and relevant medical records to:
UnitedHealthcare
600 Airborne Parkway
Cheektowaga, NY 14225
Attn: Transition of Care/Continuity of Care
Fax: 1-855-686-3561

Note: If the member has already submitted an application and you are unable to locate the status in ICUE, please send an email to ictstat@optum.com to confirm status of receipt. Set a commitment to follow up with the member once response is received. 


TRANSITION OF CARE(NEW ENROLLEE)
-specialist must be OON
-enrollee has or will have transition of care benefits
-meets the qualifications stated in REQUIREMENTS

FOR INN:
-advise that no frther action is required

FOR OON:
-Review the Requirements section to see if the member qualifies for Transition of Care.

IF MEET:
-Advise the caller the enrollee meets the preliminary criteria for transition of care, but to ensure all qualifying conditions are met, their provider can contact provider services at 888-478-4760 to initiate a transition of care request or they can complete and return a Transition of Care Application.

-Offer to contact the members rovider to advise them to contact provider service to intiate request
-If you are unable to reach the provider's office or they do not want to call in, Advise the member they can access the form on www.uhc.com/exchange (Steps to access the form are on the General Information tab.)

-If the member is unable to access form online, send a macess route to CRG-General Request to request a form be mailed to the member. Advise of TAT 7-10 business days.


IF NOT MEET:
Apologize to the member and advise they do not meet the conditions for transition of care. Offer to locate an in-network provider within the market service area. Refer to the Out of Area Out of Network Reference Guide.

Refer to the Provider Lookup (Facets CSP).

If the member still expresses dissatisfaction, then offer to file a Grievance using Appeals and Grievances.



CONTINUITY OF CARE
-if the provider leaving the network.
-check if the provider qualify for the continuity
-If qualify,offer to contact  provider services to Initiate continuity of care request.
<if unable to reach teh provider office or the provider does not want to call in,advise the member they can access the for in the members portal.
<if the caller unable to access form online,send a MACESS route to request a form be mailed to the member.Advise TAT 7-10 business days .
-Advise the member to send to the address or fax number loated on the form.

If not meet:FILE A GRIEVANCE

1023094141

To check if the member is INN using Facets:
1.log in using customer service
2.click provider at the top
3.input the NPI in provider ID field then click search
4.check in Networks section if they are INN

EXGN-if under IFP


**********************************************

PROBING QUESTIONS:
1.Do you have a doctor in mind?
2.What type of doctor do you need? Is  it a PCP or a Specialist?
3.Do you have an appointment with the Doctor?
4.Would like me to set up an appointment for you?
5.How far can you travel? 
6.Do you have any other preferences for me to select you  a doctor like gender,language?



TALKING POINTS:
*Should be included if member caclling about provider.
-State the name of the specialist first
1.Quote the benefits(cost of the visit)
2.Referral Informations( you need to request first a referral from the PCP)
3.Scheduling an Appointment

********************************************************


MEMBER PROFILING


common Redflags
-Service that are not covered
including: Dental,Vision, Transportations, Over the counter Benefits

-OON Providers
Preferred Doctor, Preferred Pharmacy, Preferred Facility
(help them look for INN provider)

-Technical Difficulties
Website Issues,Online payment, Disconnected calls
(help troubleshooting)

-Plan Confusion
Plan start date, Incorrect Information, Benefit Coverage
(apologize then educate)

-Unpaid Claims
denied Claims, Incomplete Documentations, EOB Confusions
(Try help them file an appeal)

-High Cost-Shares
Copay, Con-insurance, Deductibles
(Apologize for the confusions and educate whats all about then give examples)

******************************************

Member ID: 122312742 
Who called: Dek 
Relationship to the member: Third Party

Reason for call:
-dad//bipolar disorder // Psychologist 
-innetwork doctor nearest

Unstated concern:

Resolution Provided:
JOB AID:

Offered Schedule Commitment? Yes/No:
Callback Schedule(time and date)?:
Other concerns:____________
Wrap Up: 


HIPAA VERIFICATION IS INCORRECT
DIDNT CALLED AND CONFIRM IF THE PCP IS ACCEPTING THE PLAN AND ALSO IF THE PCP ACCEPTING A NEW PATIENT.



1.REFERRAL
Member ID: 122087906
Who called: ALEX
Relationship to the member:

Reason for call:
-pcp advised to look for cardiologist

Resolution Provided:
JOB AID:Provider Inquiries - Referral Information (IFP)	
-NEEDS REFERRAL? YES from washington
-look for the cardiologist
-call the specalists and confirm if accepting the plan and also new patient.

Offered Schedule Commitment? Yes/No:
Callback Schedule(time and date)?:
Other concerns:____________
Wrap Up: