Validation: Browser Capabilities for Pre-Authorization and Admission Notification

Type of Service	Web Site Launching Page	Applicable BPR Capabilities  Fully Met	Provider Usability Rating
Medical Services & Medical-Benefit Medications	Checking Pre-Auth Requirements: https://www.aetna.com/health-care-professionals/precertification/precertification-lists.html Submitting Pre-Auth Requests for medications, use forms found at: https://www.aetna.com/health-care-professionals/health-care-professional-forms.html Submitting Pre-Auth Requests for procedures and to check status: https://navinet.navimedix.com/sign-in?ReturnUrl=/	10/24	For the information that is available on the site
Advanced Imaging Services	Checking Pre-Auth Requirements: https://www.aetna.com/health-care-professionals/precertification/precertification-lists.html Submitting Pre-Auth Requests for procedures and to Check Status: https://www.evicore.com/pages/providerlogin.aspx	12/24

Validating Providers: Pacific Gynecology Specialists, Polyclinic, Providence Health and Services, Seattle Children's Hospital, The Everett Clinic

Validating Provider Usability Comments:

1. In most cases, providers used the automated phone system to determine whether a pre-authorization is required. The automated phone system incorporates patient specific information in its determination as to whether a pre-auth is required, whereas the web site does not. The phone system is faster and provides a fax-back audit trail. Provider wants a documented audit trail that either a pre-auth is not required or that a pre-auth was requested.
2. The automated phone system is almost always used to request pre-auths for medical procedures. With the phone system, there is a seamless transition between determining if pre-auth is required and submitting a pre-auth. If procedure doesn’t need pre-auth, the phone system provides a fax back – whereas web shows status as ‘pending review’. If the service does need a pre-auth, transfer to a person that approves or denies.
3. Whenever there is the slightest doubt, a pre-auth request will be submitted.
4. Web site is typically used only for PPO, Open Choice, Sound & Wellness plans. Phone calls are made for other self-insured plans.
5. When web site or content changes, providers are not notified or trained by Aetna. As such, web capabilities may be available of which the provider is not aware.
6. In situation where Aetna is the secondary payer, they don’t always accept the primary payer’s policy about whether a pre-auth is required. Aetna will deny for lack of pre-authorization in situations where they require a pre-authorization but the primary payer does not.

Type of Service	Web Site Launching Page	Applicable BPR Capabilities  Fully Met	Provider Usability Rating
Medical Services & Provider Administered Medications (Infusions, Injectibles)	Checking eligibility, submitting a request and checking on status - https://apps.availity.com Checking whether a pre-auth is required - https://providers.amerigroup.com/Pages/PLUTO.aspx	11/21
Advanced Imaging	Checking eligibility -  https://apps.availity.com Checking whether a pre-auth is required -  https://providers.amerigroup.com/Pages/PLUTO.aspx Checking eligibility and submitting a request -  http://www.aimspecialtyhealth.com/	10/22
Eye Surgeries (e.g. 67313)	Checking eligibility -  https://apps.availity.com Checking whether a pre-auth is required -  https://providers.amerigroup.com/Pages/PLUTO.aspx Submitting a request and checking on status -  https://govservices10.dentaquest.com/LogonProviders.jsp	10/21

Validating Providers: Confluence Health, Harborview Medical Center, Polyclinc, Providence Health & Services, Seattle Children’s Hospital, Virginia Mason, UW Medical Centers

General Comments:

For Medical Procedures and Provider Administered Medications, it is typically easier to fax or call-in pre-authorization requests to Amerigroup, rather than use the Availity website. The website asks more questions compared to that of phone or fax submissions. And some services can’t be submitted via any website and must be faxed.

Website Challenges

1. Overall Usability:

   1. There is not a link for Amerigroup on the OHP Single Sign On page.

   2. Eligibility information, pre-authorization requirements, medical policies and pre-auth request processing are on different websites, with no links to find the web page or move easily to it.

Using Availity

3. It is confusing why there is a tile for Authorization and a separate tile for Authorizations & Referrals, when both seem to work the same way.
4. Finding a patient always requires the Amerigroup ID – which is sometimes not captured in the registration process.  There is no option for lookup by Name or Medicaid ID.

2. Eligibility (Using Availity):

   1. There is inconsistency in how the status of end-date coverage is displayed.  Sometimes no end dates are reported, sometime end dates are reported as 9999.

   2. No specific benefit information is available, e.g. excluded services are not reported.

3. Determining whether a pre-auth is required (Using Amerigroup):

   1. When a service requires a pre-auth, information is not always provided about what site to use to submit the pre-auth request

   2. Some infusions require a pre-auth, but the site does not indicate the situations in which a manual form must be submitted.

   3. The site does not indicate if the service is an excluded benefit.

4. Submitting a Pre-Authorization: 

   1. Different sites - Availity, AIM, Eyequest – must be used depending upon the type of service.

   2. For some services, a pre-auth request cannot be submitted via a website, rather a manual form must be completed and faxed.

Using Availity

3. Information about the facility always needs to be entered.  Would be more efficient if a default facility could be confirmed or changed. When identifying a facility, NPI or Tax ID should be used as the search criteria.

4. When the provider is out of network, asking out of network questions, e.g. reason for out of network visit, history of treatment by out of network provider, etc. take time to answer and do not seem relevant They are not asked by other MCOs .

5. When submitting a request for provider administered medications, e.g. injectibles, entering frequency, quantity and duration can be problematic.  At times it is unclear as to what values are being requested.  Also the value of the duration must match the previously entered start and end date range. 

6. When identifying a doctor, the first name must be entered.  (A doctor’s first name is rarely known to entry staff and has to be looked up)

7. Searching for Diagnosis by Code is complicated – multiple windows are required

8. The drop down listings for the Place of Service field are not consistent with how providers think of place of service

9. Height and weight information about the patient is required on every request.

10. Can’t back up one page on the website, have to go all the way back to the home page.

5. Checking Status Using Availity: 

1. There is no single site where status information can be found about any submitted request.  Status information is only available on the site in which the request was submitted.

2. On Availity, having an “Anthem” labeled page in the process is very confusing.  Inexperienced users stop at this point and call for status.

3. On Availity, trying to access status when a Reference Number is not available is so time consuming that providers will always call rather than use the website

Process Challenges

1. Pre-Authorization requirements are more restrictive than any other MCO, e.g. tonsillectomies (42821) always require a pre-auth.  

2. Consistent information about injections and infusions is not provided when calling customer service.

3. There is not a clear process to follow when the dosage or frequency of an infusion needs to be changed.  Sometimes an MEI update is required, sometimes a new pre-auth request needs to be submitted, sometimes it needs to be handled on the phone.  At all times, multiple phone calls are required. .

4. For the same service, the Amerigroup & AIM OR Amerigroup & EyeQuest could have different medical policies.  If the vendor denies based upon their policy, the appeal must be made to Amerigroup and not to the vendor.  If the service is consistent with the Amerigroup policy, Amerigroup will reverse the vendor’s denial.  

5. Within the past 18 months the required process for getting authorizations for Radiology-Oncology services has changed at least twice.  Some confusion still exists about whether pre-auth requests for Radiology-Oncology services should be submitted to AIM or to Amerigroup.

6. Pre-auth requests and admission notifications may be denied even when documentation has been sent and received by Amerigroup.   Providers can cite multiple examples with one specific UR review nurse, where they proved the documentation had been sent appropriately, but she refused to approve – requiring them to go through the appeals process. 

Validating Providers:  Confluence Health, Harborview Medical Center, Providence Health & Services, Seattle Children’s Hospital, University of Washington Medical Centers, University of Washington Physicians, Virginia Mason Medical Center

General Comments:

Highlights

1. All authorizations are done by CHPW, none are carved out to a 3^rd party UM vendor.
2. Services are authorized in groups, i.e. not only is the requested CPT code authorized, but associated ranges of CPT codes are authorized as well.
3. Looking up eligibility information for a patient is a very simple process, only have to enter a very limited amount of member information.
4. Jiva
   1. Easy to see where you are in the request submission process, i.e. can identify which steps have been completed and which are remaining.
   2. Ability to upload documentation is much more efficient than faxing. (see D.6 below)
   3. A reference number and estimated timeframe for decision is provided as soon as submit request.
   4. Provider staff can review notes that are entered by CHPW staff to one another. This gives a sense about UR progress, likely decision timeframe and needed information. Would be ideal if the notes could be used to communicate between provider staff and CHPW staff.

Challenges

1. Eligibility & Benefits look-up. 
   1. To find a patient, the subscriber number suffix, e.g. 01, can’t be used in CHPW portal, but must be used in the Jiva portal. This inconsistency causes confusion and, at times, extra steps.
   2. Finding the date when eligibility was terminated is not straightforward. Staff has to either click down through multiple pages in Jiva or jump from Jiva to the CHPW portal. When searching for termination date on the CHPW portal, staff must guess at last effective date of coverage in order to find the termination date. 
   3. Information about a patient’s eligibility and their current coverage plan on the ProviderOne web site and on CHPW’s web site may not always be the same.
2. Pre-Authorization/Coverage Lists:
   1. Pre-Authorization and Coverage information is contained on 3 different lists (Pre-Authorization List, Prior Authorization Code Lookup, Benefit Grid) that are in two different places on the CHPW site. Staff has to jump out of the CHPW/Jiva portal to CHPW’s external web site in order to find and access this information. Efficiencies would be achieved if:
      • All the information was in one list with CPT/Jcode and description.
      • That single list was accessible within the portal being used.
   2. Updates to the information seem to happen over the course of the year, e.g. the current update date is May 5, 2017. However, there does not appear to be access to a version of the list before that update. For audit purposes, all versions of all lists should be accessible on the web site for at least 3 years.
   3. The prior authorization code lookup list can provide mis-information.
      1. Providers have been instructed that if the service code is NOT ON the list, then a pre-auth is not required and the service will be covered.   However, this is not always the case. 
         1. Unlisted Procedures are not on the list, yet they require pre-authorization.  
         2. Some services that are dependent upon diagnosis are not on the list and they may require pre-authorization or may require ‘Exception to Rule’ processing, e.g. 43235 with diagnosis of morbid obesity.
         3. Services that are Excluded Benefits are not on the list. Providers assume that these services are covered and don’t require pre-auth. Yet they are denied as not covered.
      2. Even though codes are ON the list they may not be covered and/or additional actions may be required for those services to be covered, but the list may not indicate which services to review or which actions to take.
         1. The heading on the list says: “To ensure codes on this list are covered, please verify by referring to either the National Coverage Guidelines, Local Coverage Guidelines, Noridian Fee Schedules or the HCA Fee Schedules for Medicaid based on the patient's plan.” There are not indications about the service(s) to which this caveat applies.
         2. There are situations when an infusion medication must be purchased from a specialty pharmacy. But this information is not on the prior authorization code lookup list. For example, J1566 is listed on the Prior Authorization Code lookup list with no comments or limitations listed.  However, on the Apple Health Formulary it indicates that this is a specialty pharmacy medication. The Pre-Auth Code lookup list should indicate any/all specialty pharmacy limitations.
      3. If a 5 digit number CPT code is entered in the CTRL F field, the search logic will find that string of numbers even if it spans two actual codes. For example, if 75329 is entered, the search will find a “hit” with the last four digits of 97532 and the 1^st digit of the next sequential code in the list 90870.

To decrease the risk of a denial, staff needs to make a call to CHPW or look elsewhere to determine if the service is included and if they need to get a pre-auth. As such the list is of limited value.

3. Pre-Authorization Process:
   1. For some provider organizations, both a pre-authorization request AND a referral request must be submitted to avoid a denial. From the provider perspective, these processes are exact duplications of each other which require time to complete with no added clinical value.
   2. If a pre-auth request is faxed for a service that doesn’t require a pre-auth, sometimes an authorization number is given and sometimes a letter is sent saying that a pre-auth is not necessary. The inconsistency is problematic. The preference is to receive a letter. Confusion is created when a service that doesn’t require an authorization is authorized.
4. Jiva Portal
   1. Though the request form asks for date of service, it appears as though the web site/process does not seem to associate a pre-auth request with a specific date of service. Thus, only one “active” pre-auth request for a patient can be in the system at a time. For example, if a patient requires multiple cycles of inpatient chemo and each cycle requires a pre-authorization, the pre-auth requests must be entered in sequence and the prior request must be approved and delivered before the next request can be entered. This makes it extremely difficult to submit and get a pre-auth request approved within the timeframes required for clinical effectiveness of chemo administration.
   2. During submission process, the options in the Service Type drop down list do not always match the type of service from the provider’s perspective. At times, “best guess” is used when selecting an option.
   3. If a diagnosis is entered incorrectly, it cannot be edited. To change a mis-entered diagnosis, the entire request must be deleted and everything re-entered.
   4. The use of the Assessment tab is not clear. Services are authorized without completing it.
   5. Clinical information cannot be pasted into the pre-auth request form. It must be cut from the clinical record and pasted into a desktop document. That document must then be uploaded.  This process requires extra work steps and there is an associated privacy risk as the created document may not be deleted from the desktop.
   6. Access to authorization status is needed by the organization that submits a pre-auth request and the organization that is to deliver the requested service. However, the status of an authorization request can only be viewed by the organization (Tax ID) that submitted the request. The organization to be performing the service cannot view status if they have a different Tax ID. (For example, a PCP/specialist may have submitted a pre-auth request for a service to be provided at the hospital, but the hospital cannot see that request and related status information.)  
5. CHPW-HIP Portal
   1. When viewing the list of authorizations for a patient, multiple authorizations with the same number will appear in the list and they look exactly the same. (It is assumed that multiple authorizations are listed because multiple CPT codes were authorized. However, each auth contains the exact same CPT codes.)
   2. The authorization status always seems to be “open”, it never changes even after the request is approved and the services have been provided.
   3. After selecting an authorization for a patient and reviewing the information, hitting the browser’s back arrow to return to the list causes an error.
   4. Access to authorization status is needed by the organization that submits a pre-auth request and the organization that is to deliver the requested service. However, the status of an authorization request can only be viewed by the organization (Tax ID) that submitted the request. The organization to be performing the service cannot view status if they have a different Tax ID. (For example, a PCP/specialist may be have submitted a pre-auth request for a service to be provided at the hospital, but the hospital cannot see that request and related status information.)  

Type of Service	Web Site Launching Page	Applicable BPR Capabilities  Fully Met	Provider Usability Rating
Medical Services (Inpatient procedures)	CignaforHCP.com​ https://cignaforhcp.cigna.com/navimedix/	12/23
Medical-Benefit Medications	CignaforHCP.com https://cignaforhcp.cigna.com/navimedix/ https://cigna.promptpa.com/requestpa.aspx​	12/24
Advanced Imaging Services & Outpatient procedures	CignaforHCP.com https://cignaforhcp.cigna.com/navimedix/ https://cigna.medsolutionsonline.com/portal/server.pt/community/msi_customers/204	12/23

Validating Providers:  Confluence Health, Polyclinic, Providence Health and Services, Seattle Children’s Hospital, The Everett Clinic, University of Washington Medical Center, University of Washington Physicians​ 

Validating Providers: Confluences Health, Polyclinic, Seattle Children’s Hospital, University of Washington Medical Centers, University of Washington Physicians, Virginia Mason Medical Center

Validating Provider Usability Comments:

Coordinated Care Web Site

     1. Some provides submit pre-auth requests by fax rather than using the web site because:

1. The web form requires so many fields to be submitted, e.g. date of service, whereas web form does not, e.g. date of service can be TBD.
2. The ‘Select a Service Type’ drop down list is confusing. Providers are not always clear how to map their service into one of the service types in the list. And if the mapping is wrong, the correct questions are not asked about the service.

2. The visuals on the site greatly enhance usability. The visuals could be improved so that it is easier to see/know whether the process is being done for a Ambetter member or a Medicaid member and if the Ambetter and Medicaid numbers were more visually different.
3. The web site times out too quickly.
4. Member’s name must be entered exactly as Coordinated Care has in their system or the member can’t be found. This can be problematic when names have spaces or hyphens in them. (The Medicaid number is not always available to provider staff when they are submitting pre-authorizations.) Usability of the site would be enhanced if a partial patient name match would be used.
5. For Medicaid patients, the pre-auth requirements are not always aligned with the Medicaid fee schedule. Depending upon the patient, the Coordinated Care site may say no pre-auth is required, but the Medicaid fees schedule identifies limitations, e,g, age, for when a pre-auth is/is not required. Delivering these services without a pre-auth may result in a denial from Medicaid. An extra step is required to check any limitations listed in the Medicaid fee schedules.
6. When the list of pre-authorizations are displayed, some of the numbers start with ‘OP’ and have and outpatient type but the services are inpatient, and visa versa. This is confusing.
7. Difficult to find patient/authorizations after everything has been submitted.
   1. When “Viewing Authorizations” and click Go, the system returns to the dashboard rather than just refreshing the list of authorizations.
   2. Some pended authorizations are greyed out, so that they can’t be opened and viewed.
   3. In some instances, the provider saved the screen shot of an online submission, but the request does not show up in the authorization list. Using the confirmation number to look up the authorization, it shows as being voided. However, there is no notice of a void.
   4. The Authorization dashboard by tax id show clickable Authorization ID. When click on the ID, the detail of the authorization is displayed. However, when go to patient specific authorization list, none of them can be opened.
8. If a pre-auth is required through NIA, clicking on To submit a prior authorization Login Here. should take you to the NIA site.
9. Would be useful if there was a way to save the request being submitted in the middle of the process.
10. There appears to be a messaging feature on the site. Use of this to communicate about submitted pre-auths would enhance the overall process.

NIA Web Site

1. Providers like that a pre-authorization can be checked without signing in.
2. The interactive clinical questions are difficult for non-clinical people to complete, as they have to dig through clinical documentation to try to interpret what is being asked and get the correct information.
3. When uploaded documents are submitted with a request, there is no specific confirmation that the uploaded documents were received.
4. It is unclear whether statuses from the NIA site appears on the Coordinated Care site.

Overall Process

1. Even though provider has the contract with Coordinated Care, Coordinated Care does not coordinate communications between the provider and the 3^rd party to whom they carve out UM. As such, it is time consuming and extremely difficult to get issues addressed.
2. Coordinated care is very rigid on their clinical guidelines and will not accommodate pediatric variations in the normal course of events. Most other health plans review and consider the variation within a wholistic perspective of the patient. For Coordinated Care every variation must be appealed.

More specifically, the clinical questions for Echos (Advanced Imaging) are very limited and pediatric considerations don’t fall within the categories. Peer-to-peer discussions, or appeals are usually required, to explain why the service was medically necessary even though the criteria wasn’t met.  

3. Clinical guidelines related to infusions seem to change on an ongoing basis without proactive notification to the provider.
4. The timeframe for review and decision on pre-authorizations is so long that infusions and surgeries are scheduled out 21-30 days to make sure the decision has been made before the service date.

Type of Service	Web Site Launching Page	Applicable BPR Capabilities  Fully Met	Provider Usability Rating
First Choice Health Network (FCHN) Provider Tool - for 17% of members (When Utilization Management is done by First Choice Health)	https://www.fchn.com/Providers	15/21
First Choice Health Network (FCHN) individual websites - for 83% of members (When Utilization Management is not done by First Choice Health)		0

Validating Providers: Harborview Medical Centers, Polyclinic, Seattle Children's Hospital, The Everett Clinic, Virginia Mason, UW Medical Centers 

General Comments: 

First Choice Health Network (FCHN) when Utilization Management (UM) is not done by First Choice Health – No common website or tool

1. Since the pre-authorization staff do not have a copy of the patient’s insurance card, it is difficult for them to figure out which of the network’s payor is responsible. Once the responsible payer is identified, phone calls are required since staff do not have login information for each of the payors (and they all require different login information). Phone calls are required to find out if the provider is in/out of network, whether or not the service requires a pre-authorization, to submit pre-authorization requests, and check on status. 

2. The First Choice Health Provider Tool only applies when First Choice Health does the UM, which is 17% of all First Choice Health members. Given the relatively small size of this population, for most providers it is more efficient to process pre-authorizations in the same manner for all patients, i.e. to call/fax, rather than to figure out if the FCHA Provider Tool can be used.

3. First Choice Health UM staff are extremely timely in processing pre-authorization requests.

First Choice Health Administrators (FCHA) – Provider Tool

1. Highlight: The website is very intuitive

2. Challenges: 

   1. Checking Eligibility & Benefits

      1. The ID Number suffix must be used when finding the member by ID number. Ideally, the suffix would be optional and then all members associated with the ID# would be displayed for selection.

      2. For some patients with a term date at the end of the month, the website shows these patients as Inactive even before the end of the month. Thus, pre-authorization requirements cannot be checked for these patients.

   2. Submitting a pre-authorization request

      1. When checking the pre-authorization requirements for a CPT code, a variety of different messages appear and the meaning/circumstance of each message is not always clear.  Adding the capability to “hover” over the message for a more detailed explanation would be very useful. Messages seen include:

         • Pre-authorization is required

         • Pre-authorization is not required

         • Please call FCH

         • Submit for review

         • Benefit limitations may apply

      2. Pre-authorization requirements may apply to a site of service, e.g. inpatient or outpatient, as well as to a network-partner location, e.g. a particular organization – Evergreen Medical Center. This information is not provided on the website.

      3. Not being able to search for Medical Policies by service code makes it difficult to find a particular policy. It is not always clear what Category a particular policy is located under.  

      4. When Jcodes are to be given during surgical procedures, there does not appear to be a way to submit them as 'surgical' in service type. As such, multiple pre-authorization requests need to be submitted for the same procedure, e.g. 66984 and J9190.

      5. It would be helpful if entry of a diagnosis or CPT code would display the associated description to ensure that the correct code was entered.

      6. When uploading supporting documentation (.pdf), the upload process seems to complete but the documents may not be received by FCH staff.

      7. The tool would be more useful friendly if a click would not be required to move from one screen to the next. There are many screens to complete, compared to the simplicity of completing a fax form (Fax form has fewer fields to be completed and most of them can be auto-populated from EHR system).  

   3. Getting Status information

      1. The Reference number itself is not enough to retrieve status information. Patient name and identifying number must also be entered, which takes more time and creates more work.
         If request was entered over the phone, no reference number is given. The status of these requests must be obtained via a phone call, and not online.

      2. Only minimal status information is provided:

         • With ‘Pending’ status, there is no information about where it is in the process (e.g. has it been assigned to a reviewer) and no information about the documentation that may be needed,

         • With ‘Denied’ status, there is no information about the reason, e.g. plan exclusion? medical criteria? experimental?, etc.

         • With ‘Approved’ status, there is no information on number of units or service days, frequency limitations, etc.

Validating Providers:  Harborview Medical Center, Providence St Joseph Health, Seattle Childrens Hospital, University of Washington Medical Centers

General Comments/Suggestions:

HCA web site:

1. There are services for which a number of different web-pages/documents, e.g. medical fee schedule (facility), billing guide (provider) and dental fee schedule, need to be reviewed to determine pre-authorization requirements.  Provider staff must have experience to know which document(s) need to be checked for which service.  The lack of a single web-page/document that can be checked for all services presents training and operational challenges to providers.
2. It is difficult to find the relevant limitations when “L” is listed in the Auth column of the Fee Schedule, e.g. 01922.  The Legend for the Fee Schedule says to look in the program specific publication.  But the Billing Guide for that service says to see parent program guideline.
3. Fee schedules do not comprehensively reflect Unlisted procedure requirements.  For Unlisted procedures, e.g. 31599, the fee schedule shows that no Pre-authorization is required even it is generally known that pre-authorizations must be submitted for all unlisted procedures.
4. Fee schedules / Billing Guides do not comprehensively reflect ERSO program requirements related to diagnoses.  Services for ERSO patients are only approved for some diagnosis.  Since diagnosis related information is not included in these documents, phone calls have to be made.
5. Currently ‘provider institutional knowledge’ is required to know which services, other than dental, are covered directly by Medicaid and are not covered by the MCOs.  It would be helpful if a list of these services were available on the Medicaid web site.

ProviderOne:

1. On the Eligibility/Benefits page, the name used for any particular MCO changes, on what appears to be a random basis, which makes it difficult for provider systems that run a batch eligibility check to recognize the correct MCO that applies to a patient. It would also be helpful to list, on the Eligibility/Benefits page, the MCO’s identification number for the patient.
2. It can be difficult to find out about periods of incarceration between periods of other coverage. 
3. It would helpful if data field descriptors appear when moving the cursor over/clicking on the data field, as it is not always clear what information should be put into a field.  For example, it is not clear that the decimal point should be omitted from the diagnosis.
4. When supporting documentation is attached to pre-authorization requests through ProviderOne, the Medicaid reviewers are not always able to access the documentation and it has to be sent by fax, slowing down the process.
5. When pre-authorization requests are initially entered into the ProviderOne system, and for some time thereafter, their status is shown as “Error”.  If a provider searches for this request using the provider facility ID and the patient name option, no records for the patient are ever found.  Phone calls are typically made to get information.
6. ProviderOne only reports the status of the request.  It doesn’t include letters that were faxed to the provider.  Since the letters may not find their way to the correct administrative staff, it would be useful to include those letters in the ProviderOne system.  Also, notes that better describe the status, similar to the Qualis notes, would also be helpful.
7. Clinical review approvals by Qualis are not always entered into ProviderOne in a timely manner.

HCA Policies & Procedures

1. The authorization date for a pre-authorization request is the date that Medicaid approves the request, rather than the date that the provider submitted the request.  As such, the authorization date is delayed by any Qualis backlog and review time, by transmission problems & time from Qualis to HCA and by any HCA backlog and review time.   Providers must try to anticipate all possible delays and schedule patient treatments well into the future, which is extremely problematic if/when delays will negatively impact patient health.  If a patient receives a service prior to the authorization date, the service is denied and the provider has to justify why the service had to be done before the approval date.
   It is not clear how long it will take for the Qualis and HCA reviews to be done.
2. There are times when the provider becomes aware that the commercial coverage being reported on ProviderOne is no longer valid.  However, HCA will not update the eligibility information based upon information supplied by the provider and will not process authorization requests when the commercial coverage is reported in ProviderOne.  The provider must try to get the patient contact with HCA to correct the coverage information.   This delay can negatively impact patient care.
3. Interactions with the customer service department can be challenging.  There are limited hours when phone calls are accepted and, at times, the phones are not answered even during these periods.  When reaching a customer service representative and asking about coverage information (because it is difficult to find on the web site), they may say that “the information is on the web site and that resource needs to be used rather than a phone call”. 

Qualis

1. Difficulties are frequently encountered when trying to enter physician information into the Qualis System.  Qualis appears to have a map that matches doctors to roles to facilities and providers must try to guess this map in order to correctly select and attach physicians.  In some case, e.g. Seattle Children’s, if they use the Seattle Children’s reference in the drop down menu, an error will result.  As such, they have to type in facility rather than select it.  These issues present training and operational challenges for providers.
2. Provider contact information is requested on multiple screens in the Qualis system.  Even when provider contact information is entered on these screens, the system requires them to enter contact information in the notes screen before data entry can be completed.
3. Once information is entered into the system, a series of buttons is presented, Save, Complete, etc.  If Complete is selected before Save is selected the entered data can be lost.  It is not intuitive to providers to select Save and then select Complete.  When they have completed data entry, Complete seems to be the most appropriate button.
4. Questions in the Qualis questionnaire do not match the questions in the assessment screen on the Qualis web site.   Since the providers are given the questionnaire to complete, rework has to be done when admin staff can’t complete the assessment screen because of the differences.
5. The status of ‘Approved’ on the Qualis web site is misleading as some providers think that mean the pre-authorization request is approved.  A status such as “Forwarded to Medicaid” would be more accurate and useful.

Validating Providers:  Everett Clinic, Polyclinic, Seattle Children’s Hospital, University of Washington Medical Centers

Validating Provider Usability Comments:

1. A number of providers submit pre-authorization requests via phone or fax as they are not familiar with how to do so using the web site. Training has not been provided.
2. The site is difficult to navigate and information is hard to find, even after it was previously found.
3.  When the site is used, usage is almost exclusively for:
   1. Checking eligibility.
   2. Submitting a referral request or a procedure notification.
   3. Checking on the status of a referral request or procedure notification.
   Most providers submit a request/notification for services without checking to determine if a pre-authorization is required.
4. For new/infrequent users of the web site, confusion results from:
   1. The difference between Referral Request and Procedure Notification is not known/clear.
   2. The meaning of District is not clear, so staff is not always sure which provider locations fall into which district.
   3. The Specialty listings on the site do not always correspond to how providers think about the specialty, so guessing is sometimes done. This guessing is even more problematic when the provider cannot be found because the wrong specialty was selected.
5. Favorable things about the site:
   1. Within the Eligibility Inquiry - Plan, Summary of Benefit, PCP are all easily found. Very user friendly.
   2. Within the New Referral Request - the ability to go back to the previous screen and the built in error checks are time savers.
   3. One the Injectable Drugs Requiring Prior-Authorizations list, the ability to see non-covered benefits is very useful.
6. Unfavorable things about the site:
   1. Can only enter 1 CPT code and 2 diagnoses. Any more than that have to be put into the Special Instructions section, and these don't appear on the status screen or anywhere else.
   2. Not knowing what procedures require clinical review and what procedures do not can either delay chart notes being sent or GHC would receive more chart notes than needed - with both situations delaying the process.

Validating Providers: Confluence Health, Harborview Medical Center, Providence Health & Services, Seattle Children’s Hospital, University of Washington Medical Center, University of Washington Physicians

General Comments:

A. Pre-Authorization List:

1. Having a single pre-auth list for all coverage plans is well received.
2. The pre-auth list not only indicates when a service requires a pre-auth, but also when a service is not covered. (This is well received).
3. For a given service (CPT code or Jcode), pre-auth requirements are differentiated by place of service, e.g. service needs a pre-auth for inpatient setting but not outpatient setting (which is very helpful). However, this distinction may be lost on “front end staff” who may not be aware of the significance of place of service on a claim. It would be helpful is the meaning in this distinction was clearly made on the list.
4. The pre-auth list states “All inpatient services require a pre-authorization”. However, due to the location and type font, this requirement can be overlooked. It should be made more prominent.
5. Providers are unclear whether all Unlisted Procedures are on the list and whether or not each one requires a pre-authorization.

B. Web Site(s)

1. On the Molina web site, the Eligibility information is complete and well laid out on the page.
2. On the Molina web site accessed via OHP, “Clinical Criteria” is not posted. “Clinical Criteria” is only posted on the Molina.com site. All information relevant to getting a service approved should be posted on the same site.
3. Molina web site is frequently inoperable or is slow to load pages. The site is sometimes “glitchy” in that valid entry responses are rejected.
4. On the Molina web site, searching for a previously entered pre-authorization request can take an extended period of time if the search is by patient name.
5. On the Molina web site, the pre-authorization search by Facility is problematic for some provider organizations. When viewing their Tax ID and description entries in the drop down table . . .
   1. Many of the entries appear to be duplicates which makes for a very long list.
   2. The descriptions do not clearly identify the facility so that multiple selections frequently have to be made before the pre-authorization can be found.
6. When hysterectomies are authorized, the status only displays the description “Hysterectomy” without CPT codes. For every Hysterectomy, staff has to call Molina to determine whether Providence’s CPT code is authorized. Could authorized CPT codes be listed as part of the status information?
7. Using the Clear Coverage site, pre-auth requests for Molina Marketplace members cannot be submitted.
8. The status of requests entered in Clear Coverage does not seamlessly appear as a status on the Molina web site. Requests with an Authorized or Denied status take at least several days before being reported in the Molina site. Requests with a ‘Pend’ status in Clear Coverage are never reported in the Molina site. 

C. Process

1. Molina is a great payer to work with. Their provider reps are knowledgeable and responsive. They process pre-authorizations in a timely manner (2-3 days) and they have a generous retrospective processing policy.
2. If upon review of a submitted request, Molina determines that an error has been made on the request, e.g. the incorrect ICD/CPT code is used or wrong patient/spouse name, the request is voided without informing the provider and without posting a VOIDED status. Providers wait for authorization and after a long delay call Molina only to find out that the request was voided, after an extended period on hold. Providers would prefer to be notified via fax if a request is voided along with the reason why it was voided to allow Providers to correct error in a timely manner prior to the date of service. Providers are not informed when a duplicate request is submitted.
3. An “exception to the rule request” for a non-covered service is unduly complicated and time consuming. A pre-auth must be submitted and denied before the exception request can be submitted. The submission of a pre-auth request is an unnecessary step in these cases.

Type of Service	Web Site Launching Page	Applicable BPR Capabilities  Fully Met	Provider Usability Rating
Medical Services & Medical-Benefit Medications	Premera site – Checking Eligibility, Checking Pre-Auth Requirement, Submitting Pre-Auth Request, Checking Status: https://www.premera.com/wa/provider/utilization-review/prospective-review/	20/23
Advanced Imaging Services	Premera site - Checking Eligibility, Checking Pre-Auth Requirement: https://www.premera.com/wa/provider/utilization-review/prospective-review/ AIM site  - Submitting Pre-Auth Request, Checking Status: https://www.providerportal.com/Default.aspx	14/21
Therapies - Physical, Occupational, Massage	Premera site - Checking Eligibility, Checking Pre-Auth Requirement: https://www.premera.com/wa/provider/utilization-review/prospective-review/ Evicore site  - Submitting Pre-Auth Request, Checking Status: https://www.evicore.com/pages/providerlogin.aspx	16/24

Validating Providers: Confluence Health, Providence Health and Services, Seattle Childrens Hospital, The Polyclinic, Virginia Mason Medical Center

General Comments:

Premera Site/Process

1. The web site is excellent for those benefits plans for which it can be used. Very useful features include:
   1. Ability to see pre-authorization requirements at a patient specific level (eliminates all doubt and avoids phone calls).
   2. Ability to switch between tax id numbers.
   3. Multiple services, inpatient and outpatient, can be entered and the site will provide information about whether or not an authorization is required for each. If a pre-authorization is required, the process to request one is simple and straightforward.
   4. Premera is very good at identifying duplicate requests and cancelling appropriately.

The site would be of even more value if:

1. The web site would allow for multiple ICD10 numbers to be entered for a request, as multiple diagnoses could impact medical necessity determination. (Note: Premera has now added this to their list of potential enhancements. In the interim, additional ICD10 codes can be reported in clinical notes or on the fax cover sheet.)
2. When a provider uses the Prospective Review Tool and no pre-authorization is required, the web site would generate some form of Decision ID#. The provider would be able to put this number in the patient’s record as an audit trail of the decision. Currently they need to take a screen shot for the patient record.
3. The status for all services that are carved out to a third party, e.g. AIM and Evicore, could be viewed on the Premera site.
4. When a CPT code is entered on the pre-auth tool and that service could possibly be an excluded benefit depending on diagnosis, then the pre-auth tool would present ‘check the medical policy to determine if excluded benefit’  along with a link to the medical policy.

2. Age limitations for a service are important to know. Though age limitations are reflected on the Clinical Review by Code list, these limitations are not called out in the prospective review tool. For those services where a limitation applies, that information should be either incorporated into the prospective review tool logic OR the tool should indicate that the Code List should be reviewed to determine if limitations apply.
3. Cannot retrieve an admit notification reference number (which is required for billing) online. Though Premera may fax the reference number, the fax never gets to the appropriate staff member. As such, staff has to make phone call to track it down.

AIM Site/Process

1. Useful feature of the site:

Services are approved in CPT groups. This is a significant time saver in those situations when a pre-authorized procedure changes in the course of treatment, in which case a new pre-authorization does not need to be obtained as long as it is in the same CPT group. 

2. The site could be enhanced by:

1. The link from the Pre-Auth tool should go right to AIM’s login page and not their home page. (Note: Premera will work to update this.)
2. Reducing the clinical notes field from 2000 characters to 300 characters has caused an increase in phone calls to AIM to provide supporting clinical information.
3. When the provider facility that was pre-authorized changes due to scheduling issues, the new facility cannot be updated online. Rather a phone call needs to be made.

3. The web site is not aligned with the provider’s workflow and as such is not easy to use. The clinical questions on the web site require an administrative person to interpret clinical notes, which is prone to error. It would be better if the web site allowed a choice, either: a) answer clinical questions and potentially get an auto-approval OR b) electronically upload clinical notes for a qualified clinician to review. That way there would be an appropriate path depending upon who submits the request.

The clinical questions on the web site tend to be either too specific, i.e. the specificity in the question doesn’t apply to the case at hand, or the answers are too general, i.e. don’t match the specificity in the patient notes. Both of these situations make it extremely difficult for administrative staff to complete the request correctly.

4. If the request is not auto-approved by AIM, provider must wait for a call or fax from AIM that identifies the clinical information to be submitted. Supporting documentation must be faxed and cannot be uploaded electronically.
5. A number identifying the request is not provided until a request is approved. It would be helpful if some form of reference number is generated for requests that are pended so that providers can put this number in their patient record and use it to more effectively monitor the decision process.
6. The web site logic and the reviewers do not consider pediatric guidelines and cases where the request does not meet adult guidelines, e.g. requests for echocardiogram with a diagnosis of hypertension, are always denied. In almost all cases, these denials are reversed upon appeal. (Note: Premera has requested examples and is researching.)
7. When requesting an MRI for a total spine, if three separate requests are submitted – one for cervical, thoracic and lumbar – each is usually auto-approved. However, if all three are submitted together as a ‘combo exam’ they are usually pended for peer-2-peer review.

EviCore Site/Process

1. This site is not intuitive and is quirky, e.g. if the appropriate navigator buttons are not used, the provider will inadvertently sign themselves off and will need to start the process all over again.
2. The web sites present a long and cumbersome set of clinical questions. If an answer to one of the questions is not selected, the site automatically asks for clinical information and the provider can’t go back and answer the question. As such, the request will be pended for review and will not be auto-adjudicated. (eviCore Comment: We do not allow providers to go back during the clinical collection or to  change their questions and answers by design. The site automatically asks for clinical information to allow the provider the opportunity to submit information that was either not asked, or answered incorrectly to assist in the medical necessity decision once submitted. Initially, the Physical and Occupational Therapy questions that were asked focused on changes in the condition resulting from care. However, provider’s offices were unable to provide this information since in many instances, a non-clinician was requesting authorization of services. As a result, the questions were modified to collect clinical information that is readily available in the clinical record.)
3. There is concern that the information on the Premera site about benefits remaining may not be consistent with the information provided by Evicore, i.e. which one is correct? (Premera comment: Premera has the final say as it relates to benefits remainin, which are available on the website. Due to potential lags in claims payment, visits that have been approved but not rendered or claimed, there are times where eviCore must call Premera when they think the benefit may be exhausted.)

Type of Service	Web Site Launching Page	Applicable BPR Capabilities  Fully Met	Provider Usability Rating
Medical Services	Regence (regence.com/web/regence_provider/pre-authorization)	6/22
Medical-Benefit Medications	OmedaRx	5/23
Advanced Imaging Services	AIM (providerportal.com/Default.aspx)	8/22	Auto-Approval Manual Approval

Validating Providers: Confluence Health, Polyclinic, Providence Health Systems, Seattle Children's Hospital 

Validating Providers: Evergreen Medical Center, Seattle Children's Hospital, The Everett Clinic, University of Washington Medical Center, Virginia Mason

Validating Provider Usability Comments:

1. Difficult to map the different products to the appropriate pre-auth lists. Product names on cards and websites are not aligned.
2. Site(s) are hard to navigate, difficult to find medical policies, difficult to load information, very time consuming to use, site times out and/or periodic problems entering certain fields - like phone number, can't update a request or fix a mistake.
3. On a frequent basis, the pre-auth lists are not accurate OR the UHC representative gives incorrect information related to Pre-Auth requirements, e.g. they are referring to the wrong state's Pre-Auth list.

Validating Providers: Confluence Health, Harborview Medical Center, Providence Health and Services, Seattle Children’s Hospital, The Everett Clinic, University of Washington Medical Centers, Virginia Mason Medical Center

General Comments:

A number of provider organizations fax or call their pre-authorization requests to UHC, rather than using the website, as it is easier/faster.    Websites ask more questions compared to that of phone submissions.  Most provider organizations use the site(s) to check status on submitted requests.

Highlights

1. In some cases, pre-authorization requests are auto-approved.

Challenges

  Website(s):

1. The learning curve required to become proficient with the site is very steep.
2. It is not clear which website pathway should be selected and followed for which service, e.g. imaging, procedures, and provider administered medications.  For an inexperienced user, the correct pathway is only discovered by trial and error, which is frustrating and time consuming.
3. Rather than being entered once, the username and password must be entered multiple times, once for each pathway being used.
4. Options contained in drop down lists, e.g. Service Detail, Clinical Questions, are not always clear and it can be difficult to match the information in the patient chart to any of the options in the drop down list.
5. Some fields appear to be optional (i.e. no ‘*’,) yet if they are not completed a pop up message indicates that they must be completed, e.g. patient phone number.
6. Messaging can be unclear, e.g. When trying to find/select a physician, the message “the service is not available".  "Please try again” occasionally displays.
7. When looking up pre-authorization requirements
   1. Different pre-authorization look-up pathways/processes are used for different services.  For procedures and provider administered medications, a pre-auth list must be used to determine pre-auth requirements.  For imaging services, a look-up tool must be used.
   2. UHC applies a Site of Service/Care Policy to some surgical services.  For these services a site-of-service authorization would be required and a separate pre-auth may be required.  However the pre-auth list does not indicate when both a site-of-service pre-auth and a service specific pre-auth are required.  Thus, if only the service pre-auth was obtained, the service will be denied for lack of site of service pre-auth.
   3. For imaging, the pre-authorization tool may indicate that no pre-authorization is required for a service.  However, the tool does not provide a date and time stamp for the provider to store in the patient record to prove that no pre-auth was required.  And the tool is not always correct.   Without a date and time stamp, the provider is taking a risk when using the tool.  If a pre-auth is not requested for a service that requires a pre-auth, that service will be denied.  If a pre-auth is requested on a service that does not require a pre-auth, the request for that service is cancelled without the provider being notified.  To avoid these issues, the provider will typically request a pre-auth, regardless of what the tool indicates.  The request process is time consuming, in that all of the information must be entered before the site tells them that a pre-auth is not required.  (To demonstrate that a pre-auth was not required a screen shot is stored in the patient record). 
8. When submitting pre-auth requests:
   1. Patient ID and Date of Birth must be entered into multiple screens rather than being automatically carried over from one step in the process and populated in the next step, e.g. – eligibilty, pre-auth check, and pre-auth submission.   This is very time consuming – even more time consuming for imaging services when both have to be entered for every CPT code being requested.  Also, once the patient information is entered, the site requires it to be confirmed as a separate step.
   2. Imaging pre-authorizations:  Even for the same case, a separate referral request is required for each CPT code, with the complete set of information having to be re-entered for each request along with the same set of clinical information having to be sent (even though it is all the same case).  At times, multiple UHC review nurses have reviewed the exact same case when multiple CPT codes are entered.
   3. The system is designed for grouping and entering requests by provider, which is not the typical workflow.  As such, rather than just changing the provider information, organization-specific information needs to re-entered for every request.
   4. Procedure pre-authorizations:  The provider can’t be selected by NPI or Tax ID.  The name must be entered as it is in the UHC system or the provider can’t be found. 
   5. When entering Diagnosis or CPT codes, the code must be entered AND a search for the description must be completed, requiring two steps to be performed for each code.
   6. When clinical information needs to be entered, a question is presented with a very long list of answers in a very small font.. It is often times difficult to know what information is being requested and how to match the list of answers with what is contained in the clinical notes.
   7. For procedures and provider administered medication, it is difficult to find the web page where supporting documentation can be electronically uploaded.
   8. When supporting documentation is faxed (imaging) or electronically uploaded (procedures and provider administered medications) there is no guarantee that the documentation will find its way to the reviewing nurse.  In most cases, the provider receives a call or letter asking for the information even though it was already sent.  If the provider assumes that documentation was received by UHC and doesn’t verify by calling or monitoring status, the request could be denied, even though the documentation has been sent
9. When checking status of a submitted pre-auth request:
   1. Sometimes the website will respond with ‘case not found’ even though the status is available via phone or the automated call line.
   2. Depending upon the number of services entered on the request, the status page may not list all of the services.  A phone call needs to be made to determine whether the “left off” services were still pended, approved or denied.
10. It is difficult to find the web page where Medical Policies can be found.

Process

1. For procedures and provider administered medications, the pre-auth list is not complete and not always current.  
   1. Not Complete:  e.g. Some but not all Unlisted Procedures and J-codes are on the list.  This creates confusion as the provider doesn’t know whether an omitted Procedure or J-code is/is not a covered benefit or whether it requires pre-authorization.
   2. Not Always Current:  The list may indicate that a service requires a pre-auth when it doesn’t.  If a pre-auth is requested for a service that does not require a pre-auth, UHC will cancel the request but will not inform the provider that it has been cancelled.  The list may also indicate that a service doesn’t require a pre-auth when it does.  If a pre-auth is not requested for a service that requires one, the claim for that service will be denied.
2. For imaging procedures:
   1. For some services, a “crosswalk policy” is in place where pre-authorization of one code includes authorization of other defined code(s).  However, when a claim is submitted with one of the “other defined codes” the claim may be denied for no pre-authorization and a claim level appeal is required. 
   • https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Clinician%20Resources/Radiology%20Notification%20Program/Radiology_Prior_Notification_Authorization_Crosswalk_Table.pdf
   • https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-(US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Clinician%20Resources/Cardiac/Cardiology%20Notification_Prior%20Authorization%20CPT%20Code%20List%20and%20Crosswalk.pdf
   2. Authorizations will only be approved for dates of service on or after the date of UHC review.  So for  a procedure  performed after the date requested but before UHC reviewed the case, that procedure will be denied for lack of prior authorization even if medical necessity criteria was met. 

Validating Providers:  Everett Clinic, Harborview Medical Center, Polyclinic, Providence Health & Services, University of Washington Medical Centers

General Comments:

The Good

1. Overall, the L&I web portal is very helpful AS LONG AS Claim Information can be viewed and Claims Manager doesn't need to be called (#1 BELOW). --- Information in the Claims and Account Center is excellent.
2. L&I is extremely lenient with retro-authorizations, allowed as long as a Claim is open.
3. Customer Service at Qualise Health is well supported.
4. Qualis Health returns pre-authorization request reference number right away as part of submission process, rather than faxing it back at a later time.

The Challenging

1. Secure Access Washington (SAW).
   1. Access to SAW - Knowledge about SAW is not widespread. Many providers are now aware of:
      • How to register for SAW.
      • How to set up SAW within their organization so that the appropriate individuals get access to the correct information.
      • How to change their SAW set-up if their SAW administrator is no longer with the organization.
   2. Emailing using SAW.
   • Emailing with L&I through Secure Access Washington (SAW) has recently become very problematic. Previously, when staff from a provider organization sent an email to a Claims Manager, the reply would only be send to the staff member who sent the email. Now every email sent to a provider organization is sent to everyone at that organization who has SAW access, and anyone can view, edit and delete it. So an email meant for staff member 'A' might be deleted by staff member 'B' as irrelevant before staff member 'A' sees it.
2. Access to L&I Claim Information:

Provider staff would like access and requisite training to be able to review L&I Claims Information in order to accomplish the following:

• To know about the status of an L&I Claim.
• To know the scope of allowed diagnosis.
• To know about the schedule of Independent Medical Exams (IME) and related information.
• To know if/when the pre-authorization is approved.
• To know why a submitted claim rejected and what additional information is needed.

L&I only allows Attending Provider Organizations to see L&I Claims information through SAW/Claim & Account Center and, for a single patient, only one Attending provider organization at a time will be granted access to this information. Other providers must call for information. These limitations create a burden for provider organizations.

1. Without access to SAW, staff must call L&I to find out Claim information. 
   • Oftentimes a voicemail needs to be left for Claims Manager and then provider must wait for a call back.
   • L&I policy allows CMs 2 business days to respond to a phone call. Claims Managers tend to express annoyance with providers if they feel like the calls are too frequent.
   • Once the CM authorizes a request, that information is not available for distribution to a provider for 24 hours, at which time the authorization information is mailed. Provider staff needs documentation of this authorization to place in the patient record for audit purposes. Mail rarely, if ever, gets to the correct staff member in the provider organization in a timely manner, if at all. Even upon request, the CM will not email nor fax this information to the provider staff member.
2. If a patient has previously seen a provider and then wants treatment with a new provider, the new provider does not have access to the Claim information for that patient until the new provider is the Attending Physician. The new provider needs to call the CM to get access to Claims information and this can take awhile.

3. Fee Schedule:
   1. The fee schedule is based on a July-June fiscal year rather than calendar year. However, few providers are aware of this fact. Thinking that the fee schedule is no longer current, from Jan-June they call on many of the services to confirm the information that is reported on the fee schedule. 
   2. A number of services, e.g. CPT 20610, appear on the Fee Schedule as covered with the Prior Auth field being left blank. Since the provider needs clear documentation about whether or not a service requires authorization, they call the CM on every one of these services and then the Claims Manager documents the conversation under the L&I claim file notes. To avoid the time and expense of these phone calls and the extra work by the CM, a ‘No’ should appear in the Prior Auth field when a service never requires Prior Auth. Additionally, if the procedure just requires a notification to the CM, ‘Notification’ should be listed under the Prior Auth column, instead of a blank column.
4. Undetermined Claims:  The administrative processing for an Undetermined Claim is complex and time consuming. While a Claim is Undetermined, staff must continually check back to monitor before the pre-auth request can be submitted. 
   1. For diagnostic services, phone calls need to be made to the Claims Manager to check status of L&I Claim prior to submitting an authorization request either to Qualis Health or CM. If the L&I Claim has been created and is found to be Undetermined, a pre-auth request can then be made on a diagnostic basis. However, if Claim has not been created/could not be found in Secure Access, follow ups will need to be made to determine if an L&I claim has been created. Improvement Opportunity: Automated notification to appropriate provider organizations about status of L&I Claims would reduce phone calls, work load, and delays in patient treatment.
   2. For PT services, providers follow the standard approval process as if the L&I Claim was open, i.e. no pre-authorization required for visits 1-12, Claim Manager approval required for visits 13-24, UM approval required for visits >24. Bill for services are typically submitted in the order the services were provided. For as long as the Claim is Undetermined, bills submitted for treatment services are denied by L&I (rather than pended). Providers must periodically monitor the Claim in order to know when it is not longer Undetermined so that they can rebill for each of the services. In most cases, L&I “approval” of the L&I Claim happens after a number of PT services have been completed, billed and denied. The most problematic scenario is when the claim is approved after the patient has received 24 visits. Here is that scenario;
      • During the time the claim was Undetermined, providers treat the patient and send bills to L&I, e.g. for treatments 1-24.
      • L&I denies the bills for treatments 1-24 since the claim is Undetermined.
      • Provider happens to send in bills for treatments 25 and 26 just after the L&I Claim has been approved. L&I pays those bills.
      • When the provider discovers that the bills for treatments 25-26 were paid, they resubmit the previously denied bills for treatments 1-24. In the meantime, the have already submitted the bills for treatments 27-30.
      • L&I processes bills for treatments 25-30 as if they are treatments 1-6, without consideration of authorization numbers. (Provider obtained authorization numbers for treatments 25-30. However, since L&I processed them as the first 6 treatments, the authorization numbers were ignored by L&I payment system).
      • When L&I does processes bills for treatments 1-6, which are actually the 25-30 treatments processed, L&I denies those bills since they do not have authorization numbers. (No pre-authorization is required for treatments 1-12).

To avoid this situation, L&I should pend service claims for an Undetermined Claim. If the Claim is not approved, the pended claims for service should be denied. If the Claim is approved, the pended claims for service should be paid in either the order that they were received or order of service date.

5. Qualis Health Site: 
   1. Qualis Health site is comprehensive, however it is not intuitive and the learning curve is very steep. For provider organizations that see a limited number of L&I patients, staff must stop what they are doing and either call Qualis Health with questions or try to find the answer in the manual.
   2. Only one diagnosis can be entered.
   3. For multiple Diagnostic Imaging procedures (e.g. MRI), separate requests need to be made for each image and the same documentation has to be sent with each request and multiple reference numbers have to be managed.
   4. When requesting a pre-authorization requiring UR, a Questionnaire oftentimes has to be completed on the Qualis Health site. Some of these Questionnaires, e.g. Spinal Injection Questionnaire, PT Questionnaire when >24 visits are being requested, require a level of clinical competency to answer. However, provider staff completing these questionnaires do not have the requisite level of clinical training to make some of the determinations. Since the request is submitted along with supporting clinical documentation that will be reviewed by clinical staff at Qualis Health, why not eliminate the requirement to complete the questionnaire.
   5. It would be of value if the Qualis Health site notified staff when the status of a request changes, so that staff wouldn’t have to constantly go to site to check if anything new has happened.
6. PT/OT Visit Counts: Due to benefit coverage limits and pre-auth requirements, providers are keenly interested in visit/service counts for Physical Therapy and Occupational Therapy. It is a time-consuming process for them to go through the Claims information and try to count the number of paid claim in order to determine visit/service counts. However, when the provider calls the Hotline, the representative provides them a count instantaneously. To avoid the time and expense of these phone calls, the services counts should be transparent on the Claims information screen.