Requesting authorizations for outpatient services

Rilee Ajiri, BSN RNManager, Health Care Management

Universal precertification form

IAPEC-0999-18 July 2018

Amerigroup Iowa, Inc.provider website

• Claims and Billing Manual:

– https://providers.amerigroup.com/ProviderDocuments/IAIA_ClaimsandBillingRefManual.pdf

• Precertification Request form:

– https://providers.amerigroup.com/ProviderDocuments/IAIA_UniversalPreCertUpdate.pdf

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What requires precertification?

• Precertification Look Up Tool (PLUTO):– Visit http://providers.amerigroup.com/Pages/PLUTO.aspx.– Enter a code to receive a

Yes or No answer.– If you receive a Yes, submit

a precertification form viafax or Availity.

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Section 1: member information

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Section 2: referring provider

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Section 3: servicing (billing) provider

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Section 4: servicing facility

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Section 5: requested service

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Submitting clinical information

• The clinical guidelines and medical policies search can be found at https://medicalpolicies.amerigroup.com/search.

• Follow the criteria listed for each modality.• All outpatient services will be reviewed using the criteria in the

clinical guidelines/medical policies.

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What should be markedurgent versus standard

• Urgent:– In order to be marked as urgent, the request must meet the

criteria.– There is a contractual obligation and definition in the contract

(section 11.2.1):• “(2) Expedited authorization decisions. (i) For cases in which

a provider indicates, or the Contractor determines, that following the standard timeframe could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function, the Contractor must make an expedited authorization decision and provide notice as expeditiously as the member’s health condition requires and no later than 72 hours after receipt of the request for service.”

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What should be markedurgent versus standard (cont.)

• Nonurgent:– Will be processed within the 14-day turnaround time per the

contract (section 11.2.1):• “(1) Standard authorization decisions. For standard

authorization decisions, Contractor shall provide notice as expeditiously as the member's condition requires and within 14 calendar days following receipt of the request for service, with a possible extension of up to 14 additional calendar days…”

– Examples of standard, nonurgent requests include:• Submission of additional clinical service for a pended review.• All outpatient scheduled therapy.• Any planned procedure.

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Helpful tips

• Submit current medical information. • Submit the most recent progress notes stating the progression

toward goals or barriers to progress, home exercise plans, etc.• Submit signed orders from the requesting doctor.• Submit all current lab values/tests that support the request.• Submit your request with all supportive clinical medical

documentation at the same time.• Allow for the full 14-day review period.

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Helpful tips (cont.)

• Refer to the provider site for the guidelines your request will be reviewed against and submit the appropriate documentation as listed.

• Make your best case for the member in your initial request with all supportive documentation to allow our clinical staff to move the request along.

• Use PLUTO as your guide and source for whether precertification is required.

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Thank you!

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