Effective October 1, 2019, the UnitedHealthcare Community Plan requires Primary Care Providers (PCPs) or referring specialists to submit authorizations for evaluation and re-evaluation requests for physical, occupational, and speech therapy services in all settings.
This change was applied to the following UnitedHealthcare Community Plan programs:
• UnitedHealthcare Community Plan (New York State Medicaid Managed Care Plan)
• Child Health Plus
• UnitedHealthcare Wellness4Me (Health and Recovery Plan – HARP)
• Essential Plan
After initial evaluation, therapy providers have to submit authorization requests to UnitedHealthcare for therapy treatment.
WCH has been receiving a huge volume of questions from therapy providers since the updates came into effect. People are still confused about the updates, and the system doesn’t seem to be ready for the implementation.
The online options for prior approval requests for therapy providers were not working properly. For those patients where authorization was required the system was giving a notice that it was not required. The UHC support line representatives explained this as a system error and advised providers to keep those notices for appeals purposes in case therapy gets denied because of the absence of authorization.
Providers spend valuable time to comply with the payer’s requirements, and as a result of those efforts, they also may be forced to prove their rights through the appeals process.
The most confusion was around the referring provider prior authorizations requirements to initiate the therapy. Referring providers must obtain prior approval from their own provider login. It is not a referral but prior approval! It goes through a plan approval process (review of medical necessity), while a service that requires a referral does not go through an approval process.
What’s New under the Updated Prior Approval Requirements of FidelisCare?
Therapy providers must request prior authorization through the National Imaging Associates, Inc. (NIA) for all services after the initial evaluation for all Fidelis Care Members under the following health insurance products:
• Medicaid Managed Care (NYM)
• Fidelis Care at Home (FCAH) (Managed Long-Term Care)
• Child Health Plus (CHP)
• HealthierLife (HARP)
• Qualified Health Plans (Metal-Level products)
• Essential Plan (EP)
Initial evaluations do not require prior authorization. However, all other procedure codes, even if performed on the same date as the initial evaluation date, will require authorization.
Authorization requests can be initiated at www.RadMD.com or by calling NIA at 1-800-424-4952
It should be noted that you still need to ensure that the member’s therapy benefit has not been exhausted prior to providing services, even if an “Approved Authorization” has been obtained. For example, The Medicaid and benefits are limited to 20 visits per member for Occupational and Speech Therapy per calendar year and 40 visits for Physical therapy. Benefits can be verified with the FidelisCare directly.
FidelisCare will continue to manage prior approvals for therapy providers for all services after the initial evaluation for FidelisCare Members under the following health insurance products:
• Medicare Advantage (MA)
• Dual Advantage (DUAL)
• Medicaid Advantage Plus (MAP)
FidelisCare will continue to manage prior approvals for for Non-Therapy Providers (MD, DO, etc.) for all health insurance products.
A significant update for therapy providers is that for members with FidelisCare as a secondary an authorization is also required!
How to Manage the Authorization Process
Here are some tips you should take into mind when planning on managing your authorization process:
• Check the eligibility accurately for the primary and secondary payer. Ensure that the member’s therapy benefits have not been exhausted and keep in mind that FidelisCare requires authorization even in the case it is a secondary.
• It is recommended that you check eligibility at the time of each visit. Sometimes, providers may obtain prior-approval for the treatment that covers several months, but the patient may change their insurance. Therefore, the office must initiate a new authorization with a new payer.
• Do not schedule additional visits until authorization is obtained. That’s because in some cases, it may take around two days to get a response from a payer, and approval may contain future dates.
• Make sure that authorization has been obtained for the correct servicing location, under accurate TAX ID, and rendering provider name and NPI. Make sure the obtained prior-approval contains accurate information. Authorization obtained must match the services rendered, including diagnosis codes.
• Keep copies of the payer’s responses (even if the response is stating authorization was not required) and note each conversation with the payer indicating the date, time, and representative’s name and call reference number.
• Track the authorization limits and expiration dates. For example, UnitedHealthcare gives prior approvals for a number of visits with an indication of the maximum number of units. You must track accordingly. Prolong the authorization in advance, when needed. Use program solutions for better management of authorization limits and expiration dates.
If you need to know more about program solutions, you may contact the WCH IT department at firstname.lastname@example.org.
• Provide the prior-approval information (copy) to your biller including the prolonged approval/authorization.
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We hope you will find this information helpful for building your internal processes. Contact us today if you have any additional questions.