SAR Overview - AlphaCM · Web viewReflects any limits set outside of the basic scope for the...

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SARS Overview

SAR OverviewThe SAR module (Service Authorization Request) is used to request services for a consumer to in return receive an Authorization to do so. This guide will cover how to successfully enter and submit a SAR. Be sure to check our online demonstration video, and other videos, located on the University at the bottom of the web page.

To launch the SAR module, click on Menu > Clinical > Utilization Management > SAR.

Module View Rescinding a SAR SAR Under Review SAR is Approved

SAR Tab Clinical Tab Docs Tab

SAR Tile Service Tile PCP Tile

Service Tile Target Pop Tile Patient Notes

Provider Communication Tile SA Tile Clinical Docs

Diagnosis Tile Previous Auths Tile Clinical Tags Tile

View SAR SAR Transfer History Service Tile

Appeal Tab Creating a SAR Deleting a SAR

Appeal Tile Logistics

Appeal Comments History Diagnostic Profile

Guideline/Service Def. Substance Abuse

Medical Use

Clinical Documents

Request for Service

FAQS Work Flows

Note: It is best to Save your work and Save often as IT issues may occur that are out of the MCO and AlphaCM’s control. Issues such as ISP connectivity and internal network blips could cause you to lose your connection and be forced to log out, then back in.


SARS Overview

Module View (TOP)

After the module loads, you will be presented with four (SAR, Clinical, Docs, and Appeal) tabs and numerous tiles for each tab:

You can Filter for a specific SAR options based on the information you currently have.


SARS Overview

SAR Tab (TOP)

SAR Tile

You can think of the SAR tile as the Header of the SAR. This is also the prominent tile of the module, meaning that the data populated in the surrounding tiles throughout the module will be dependent on the SAR record selected in this tile.

*Note - Depending on the amount of data, it is common to wait 2-8 seconds for the tiles to populate.

Fields

SAR #/ID: The AlphaMCS unique ID number for this particular SAR

Agency: Displays the agency(provider) name

Patient Name: Displays the name of the consumer to which the request is for

Type: Scope of SAR (MH, SA, DD)

Status: Displays the current standing of the SAR

Request Type: Will be either “Initial” or “Reauth”

Placement Recommended: The LOC Recommendation

Service List: Service(s) being requested on the SAR

Remaining Days: MCO’s have 14 days from date of submission

Expedited: Checkbox indicating the MCO has 3 days to render a decision

Retrospective: Checkbox indicating that client received coverage from another insurance

for a past date, and claims need to be readjudicated under that new

insurance.

Buttons

Update: Allows the current owner to make changes to a non-submitted SAR


SARS Overview

Copy Sar: Quickly create a new SAR for a patient using an existing SAR

Assign: Assign a SAR to a member of the UM department

Take Assignment: Assign the selected SAR to yourself

Rescind: Allows Care Coordinators the ability to Rescind a SAR they’ve submitted

Note: Auth Created Number: The authorization number created after a SAR has been approved is a combination of the Auth #, the year and the month in YYYYMM00000000 format. So ‘20120300014004’ indicates the Authorization number is 14004 and was authorized in March of 2012. When searching you can enter either the entire number or just the authorization number.

Service Tile (TOP)

The Service Tile is used to quickly reference the details of the service(s)requested on the SAR.

Fields

SAR #: Unique AlphaMCS assigned ID for the selected SAR

Proc Code: Service being requested for authorization

Proc Description: Description of the service being requested

Requested Units: Number of units requested for this service

Current Approval Status: Current status of this particular service on the SAR

Last Submitted Date: Used during the appeal process

Site Name: Name of the site being requested for authorization

Update Date: Last time this service request was acted upon

Update By: Displays the name of the MCO staff who updated the Service line

Deny Reason: Displays reason if MCO denies the service

Current Owner: User ID of the currently assigned user


SARS Overview

Auth Created: Indicates an authorization was created in AlphaMCS

Auth Created Date: Date the authorization was created

Initial Submission Date: Displays the first time this authorization was submitted

Submitted: Indicates whether the SAR was submitted to the MCO

EPDST Approved: Indicates if MCO is reviewing under EPDST

Peer Reviewer Name: Name of user assigned for peer review

Funding Source: Benefit Plan of the SAR (Medicaid or State).

Comments: Displays any comments made by the MCO.

Approved Limits: Reflects any limits set outside of the basic scope for the Service.

EPDST Justification: Displays EPSDT justification comments.

Credential: Peer reviewer credentials (e.g. – MD)

Approved Units: Unit per increment (e.g. - 1 per Day)

Approved Total Units: Grand total units approved for this service and authorization period

Buttons

Update: Allows the current owner the ability to review and submit a decision

View: View the SAR without the ability to modify or submit

Notice of Extension: Generate a Notice of Extension letter for review extensions

EPSDT Details

(TOP)

If the Provider submits a SAR with EPSDT checked, the EPSDT Approved box will not be have a check in the box by default.


SARS Overview

If the Provider submits a SAR without EPSDT checked the use of the Additional Justification checkboxes are still available with any level of denial.

EPSDT APPROVED check box: o Will not be available if a SAR is FULLY DENIED

o Will be available if a SAR is Partially denied

EPSDT Additional Justification area:o Will not be pulled into Letterso Is not viewable to the Provider


SARS Overview

SAR- Clinical Justification, Provider Communication, Alternative Services, and EPSDT comments. (TOP)

In the Service tile there are four categories for reviewing the comments history. Comments are created whenever a SAR is transferred between MCO staff or by simply clicking the create button:

Click Create in the appropriate category, then choose the comment type and again click Create.


SARS Overview

Type in the comment, upload and needed info and click Save.

*You will see the success message and email confirmation box will appear.

After clicking OK on the success message, you will be exited back to the four categories of the Service Tile and the most recent comment will be at the top of the list:


SARS Overview

Diagnosis Tile (TOP)

The Diagnosis tile is simply used to identify what Diagnosis or Diagnoses are recorded on the SAR:

View SAR Tile – View Only

The view SAR tile is just that; a tile to View the SAR that was entered and all of it’s elements. Below is an example (SAR entry will be covered thoroughly in the Creating a SAR section of this document):


SARS Overview

Provider Communication Tile (TOP)

The Provider Communication Tile is used to exchange information from Provider and MCO.

When in this tile click CREATE:


SARS Overview

Choose a comment type that needs to be known by Provider and MCO. You can upload documents and/or type/paste text into the comment field.

Note: If “Need More Info” is chosen a new button appears in the Service Tile titled Additional Info:

Through the use of this button a request for more info can be submitted:

Once the Additional Info is requested an email is sent to have this extra detail added to the SAR.


SARS Overview

Once that info is satisfied, you then can go back into the Provider Communication tile, choose CREATE once more and chose “Request Info. Provided”, add any comments and save.

That will remove the Additional Info button in the Service Tile:


SARS Overview

Clinical Tab (TOP)

The Clinical Tab will display the clinical information on the SAR. There is also a tile for the SAR Transfer History and the history of Previous Authorizations for the consumer which may have a role in the MCO’s decision:

Service Tile

The Service tile is brought over from the SAR Tab as a reference point. Full explanation above under the SAR tab section:

Note: The user will not be able to select a different SAR when the service screen is open. If the user clicks on a new SAR without closing the Service screen, the selection on the SAR tile will revert to the original SAR and the user will receive an error.


SARS Overview

Target Population Tile (TOP)

The Target Population Tile is used to reference currently active TPs for the consumer from the SAR selected. You can click your “3” view to identify additional information such as Insert Date and Insert User:

Substance Abuse Tile

The Substance Abuse tile will display the SA record that was submitted on the SAR selected from the Base tile:

Previous Auths Tile

The Previous Auths tile is used to identify prior Auths for the consumer. Clicking your “3” view on this tile will give you additional information such as insert date and used Units. You will notice that one of these lines has the service listed as ALL. This is b/c All services within a particular Service Definition was authorized; covered in the Creating a SAR section:


SARS Overview

SAR Transfer History Tile (TOP)

The SAR Transfer History tile is used to track “change of hands” among the MCO staff. This will display each time the SAR is transferred from one staff to the other and displays the timestamp and comments for the transfer:


SARS Overview

Docs Tab

PCP Tile

The PCP Tile is used to display any PCP plans you have uploaded for this consumer via the Treatment Plan module. This can be utilized to quickly review the consumers plan by clicking the document name in the Doc Name field:

Patient Notes Tile (TOP)

The Patient Notes tile is used by the MCO to add notes and details about the consumer.


SARS Overview

Clinical Docs Tile

The Clinical Docs Tile is used to quickly access supporting documentation that was submitted with the SAR:

Clinical Tags Tile

The Clinical Tags Tile can be used to create tags. Once they are created, they can be updated with new details.

Service Tile

The Service Tile is a copy of the one in the SAR tab.


SARS Overview

Appeal Tab

Appeal Tile

The Appeal Tile is used to reference the appeal process if you are a provider, family member or doctor. An appeal for a denied SAR needs to be initiated by communicating directly to the MCO. You can use this Tab and its tiles within to review the progression of the process:

Appeal Comments History Tile

The Appeal Comments History Tile is used to reference any coments, status and any supporting documentation during the appeal process:

Guideline/Service Definition Tile


SARS Overview

Creating a SAR (TOP)

To create a SAR, launch the SAR (Menu>Utilization Management> SAR) module. Once it loads, click the Create button:

When the SAR Entry screen loads, you’ll see that it is broken down into six different sections. Each one is covered individually in this section of the SAR guide:

Logistics

The first section you’ll come to is the Logistics section. The first thing you want to do is click the Search button to search for your consumer you are submitting the SAR for. After clicking search you will be presented with a common search filter in order to identify the consumer for the SAR:


SARS Overview

Diagnostic Profile (TOP)

In this section of the SAR you will record the consumers Diagnosis or Diagnoses. This is a “populate as you type” field, meaning, you must click an option from the list for the Dx to register correctly in the system. You can start by typing the numerical code or key words in the description. Each field is numbered which will correspond with an Axis:

Substance Abuse

The Substance Abuse section is used to record any controlled substance that the consumer could be abusing as the source for requiring services:

After clicking Add:


SARS Overview

Medical Use (TOP)

The Medical Use section is used to document information such as the Primary Care Physician, if a release form has been signed, any medication the consumer is currently on and any allergies the consumer may have. The data entry process in this section is slightly different than the SA section. Here, you will enter the Medication and then choose + if you want to add multiple medications:

Clinical Document

The Clinical Document section is used to attach and upload supporting documentation to the MCO that will be used in rendering a final decision on the SAR:


SARS Overview

Request For Service (TOP)

The last section in the SAR to fill out to successfully submit to your MCO is the Request for Service section. The first thing you will select here is the benefit plan you are requesting services from. Since my consumer has only State eligibility, State is my only option to choose from. You can confirm this in the Patient Module.

Note: When requesting a Service Code, you will see an option for ALL. This will request ALL services within the definition selected that you are contracted for. Meaning; if a service definition has 10 services associated with it, but the site selected is contracted for 3 of those services then those 3 services will be included when you select ALL.

At the bottom of the SAR page you can add an additional service to include on the SAR. To do so, choose Add Service. Other wise, you can print and Submit your SAR to the MCO for review:


SARS Overview

Deleting a Saved SAR (TOP)

In AlphaMCS, you have the option to delete a saved SAR if for some reason the SAR was entered in error.

You would first find the SAR you submitted in error and select the “Update” button.

Then scroll to the bottom of the SAR and select the delete option.

A pop up box will then display for you to enter the reason for deletion and then select save.


SARS Overview

Rescinding a SAR (TOP)

In AlphaMCS, you have the opportunity to rescind a SAR that you have submitted it and MCO staff have not taken any action on the SAR.

View of the Rescind button under the “3” view.

The below screen will display for you to record the reason for the rescinding:

Now you are able to make your updates and re-submit:

Until an update is done, this is what the MCO sees after opening the Rescinded SAR that is not yet ready to be submitted with the corrections.


SARS Overview

SAR Under Review (TOP)

Within the SAR module, you have the ability to stay informed of the current status of your SAR. You can review the SAR timeline by clicking on “View SAR Cycle” or going back and looking at your SAR Transfer History tile under the Clinical tab. You can also look at the SAR header for the Remaining Days, Status and Decision Submitted indicator (as in the picture below).

SAR Header Status

View SAR Cycle (SAR Timeline)

Note - CC's will be alerted when a decision has been made to a SAR of a Patient that is in their Caseload.


SARS Overview

After a SAR is Approved (TOP)

After a SAR is Approved, the consumers service Authorization is automatically created in the AlphaMCS system and claims can be submitted for the consumer. You can print the Authorization Letter out of the Authorization module explained in the Authorization Guide.


SARS Overview

FAQs

-I’ve approved the service but it looks like the number of units is wrong…

Make sure when you approve a service, you’re entering the number of units you approve for a certain time period in the Approved Units field. When you click off or tab out of this field, the system will automatically calculate the Approved Total Number of units (Approved Units x Approved Duration Definition).


SARS Overview

-I’ve approved the service but the status looks wrong…

Make sure you change the status of the service by clicking the appropriate radio button towards the top of the form, above the Approved Units section. Even if you approve the units, you need to change the status.

-Do I have to enter daily/weekly/monthly/yearly limits when I’m approving a service? Shouldn’t these limits already be in the system?

The limits are already in the system. You would enter limits here if you want different units than what is set up in your Benefit Plan. To see current limits, go to the Benefit Plans module and look at the Services/Procedure Codes tile.

-Do I have to print authorization letters for providers?

No, you don’t. But if you want to print the letter, you can do this by going to the Authorizations module. (see Authorization Document on the University for these steps).

-Do I have to print denial letters for providers?

No, you do not. The letter is available electronically for the Provider to print at any time by accessing the denied service and clicking the “3” view button. Then click on the “Denial Letter” button. The Provider can also view the decision status electronically on each SAR.

-If I change a service definition in the system, will this affect the authorizations of any services tied to that definition?

In most cases, no. The only reason an authorization would be affected is if on the SAR, “All Services” was chosen in the Services dropdown.


SARS Overview

Workflows

AlphaMCS Submit Validation Process

AlphaMCS Provider View of Request for Additional Information


SARS Overview

AlphaMCS Denial and Appeal Process

SAR Overview - AlphaCM · Web viewReflects any limits set outside of the basic scope for the...

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