Insurance PreAuthorization is a requirement from a health insurance company, under which a clinic obtains permission from the insurance plan before it covers the cost of a patient's treatment or other medical services. This permission is tracked with the help of a PreAuthorization number. Whether to get PreAuthorization for a treatment depends on the insurance type and insurance plan coverage for the patient, which can be seen from the Insurance Eligibility information.
The Insurance PreAuthorizations popup is invoked after clicking the Pre Auth button on the Patient Insurance screen and is used for tracking PreAuth information. The PreAuth details of a patient for a selected insurance company are displayed in tabular form in this popup. PreAuth details are also added to the table on this screen from the CPOE → PreAuth Tracking screen when the PreAuthorization request being tracked is approved by the insurance company.
The following is a description of each field in the table on this popup:
Del checkbox: Select this checkbox and click the OK button to delete a PreAuthorization record.
Note:
A PreAuth used in an encounter can be deleted without any validation.
Auth #: Enter the authorization number provided by the insurance company for a specific treatment. A PreAuth number does not contain special characters.
PreAuth Usage icon: This icon is displayed for all PreAuth rows that were saved previously. Fill in the PreAuth details, click OK, and open the Insurance PreAuthorizations popup again to find this icon for a newly saved record. This icon invokes a popup that displays the Order Details with which the PreAuth is associated, along with its Usage History.
Note:
Along with the type, the Usage History also presents the status of the respective types, such as Appointment - Completed, Claim - Billed, etc.
Charge Code: Clicking the search icon next to the Charge Code field invokes the CPT/HCPCS Search popup, through which the charge codes for a treatment can be selected for which a PreAuth Number has been issued. This CPT/HCPCS Search is powered by IMO. If a PreAuth Number with a charge code is associated with a claim, the system expects that charge code to be billed on that claim; otherwise, that PreAuth No. is removed from the Charges Table of the Claim. Only one charge code can be associated with a PreAuth No. in one row. If the same PreAuth No. is valid for multiple charge codes, then the same PreAuth No. can be defined in multiple rows with different charge codes associated with each row. PreAuth details can also be saved without entering a charge code.
From Date: Refers to the date from which a PreAuth number is valid and can be used. It is validated against the Encounter Date, which is the same as the Claim Date of Service. This is a mandatory column. If the From Date is not entered for a PreAuth record, a validation message that reads 'Please enter "From Date"' stops the user from saving the record. The From Date can either be selected from the calendar icon placed on the right side of this field or can be manually entered in MM-DD-YYYY format.
Upto Date: Refers to the date up to which a PreAuth number can be used. It is validated against the Encounter Date, which is the same as the Claim Date of Service. This is not a mandatory field. The Upto Date can either be selected from the calendar icon placed on the right side of this field or can be manually entered in MM-DD-YYYY format.
Visits: Enter the total number of visits that can be used with a PreAuth No. If this field is kept blank before saving the record, the default value shown in this field is 0.
Note:
A PreAuth record with 0 visits is not reflected on the Pre Auth popup that is invoked by clicking the PreAuth hyperlink on the Appointment Schedule; hence, it cannot be associated with a claim on the Edit Claims screen.
The Visits field can later be edited from the 'Insurance PreAuthorizations' popup of the Patient Insurance screen.
Initial Used: Enter the number of visits in which the PreAuth is initially used. Here, 'Initially Used' indicates the use of this PreAuth in earlier encounters before making an entry of the PreAuth in this table, and is therefore not tracked in the used count. If a value is not entered in this field before saving the record, the default value is shown as 0.
Comments: Enter comments related to the PreAuth record, if any. This field is not mandatory and, therefore, can be left empty. This field supports alphanumeric and special characters and has a character limit of 255.
Closed checkbox: Select this checkbox and click OK to stop further use of this PreAuth No. record. Once checked, the checkbox can later be unchecked without any validation.
Used: This column displays the count of visits in which this PreAuth number is used. The value of this field cannot be changed manually. It changes automatically in two scenarios:
- When initially used: While defining the PreAuth in this table, when the Initial Used field is populated with a number less than or equal to the number in the Visits field, the Initial Used count is added to the Used field.
- When an Encounter starts (i.e., when an Appointment is marked Arrived): For a PreAuth No. associated with an appointment, the Appt count is decreased by 1 and the Used count is increased by 1 upon starting an encounter for a patient.
Later, the same PreAuth is associated with a claim created by closing that encounter.
This PreAuth is sent with the billed claim information.
Until the claim is billed, the PreAuth number associated with it can be removed, resulting in the reversal of the Used count.
In other words, the Used count of a PreAuth is the sum total of the PreAuths initially used and the number of appointments with associated PreAuths marked as "Arrived" to start an encounter, with the association not removed until the claim is billed.
Bal: This column displays the number of approved visits remaining for a patient where the PreAuth number can be used. Values cannot be entered manually in this field. This field is auto-populated when values in the Visits and Initial Used fields are present. When the Visits and Initial Used counts are not specified, this field auto-populates a null (0) value.
Note:
- The total number of visits associated with a PreAuth No. (Visits column) is the sum of visits for a scheduled appointment (Appt column), visits used (Used column), and the balance number of visits (Bal column), i.e., Visits = Appt + Used + Bal.
- When the PreAuth popup is invoked from the Billing Module, Edit Claims screen, the user is presented with an option to add a new PreAuthorization number from the same popup.
Cancel button: Click to cancel unsaved changes and close the popup.
OK button: Click to save the entered details or changes made in this popup and close the popup.
History button: By clicking this button, the Insurance PreAuthorization History popup is invoked.