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- Hello. I am here today to remind you all about Authorization review both for Contracted and Non-Contracted Providers.
- When validating for authorization, make sure to review all possible locations to avoid incorrect denial. Authorization can be found on the following locations:1. Facets Match UM2. Facets Prospective UM3. JIVA/Guiding Care4. Sometimes attached to the claimNote: For SRG/OneCare claims outreach maybe needed if there is no authorization on file, but for OneCare RTP may also be necessary after outreach if there is still no authorization.
- Aside from validating authorization from MATCH/Prospective UM, JIVA and any attachments, Prior Authorization List should also be reviewed. Any services not listed on the PA List for Contracted Provider will not require Authorization, including Sensitive, STD, Abortion, Family Planning, Minor Consent, HIV testing, Basic prenatal care, Routine obstetric, Pediatric, and Primary and preventive care services.
- Remember, Non-Contracted Provider will always require authorization except for the following services:1. ER/Urgent Care Visits2. Dialysis3. Services rendered by PCP 4. Ambulance (inter facility and emergency)***The above exclusion also applies to Contracted Provider
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