Insurance PreAuthorization is a requirement from a health Insurance company as per 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 Insurance Eligibility information.
The Insurance PreAuthorizations popup invoked after clicking the Pre Auth button from the Patient Insurance screen and is used for tracking PreAuth information. The PreAuth details of a Patient for a selected Insurance Company is displayed in tabular form in this popup. PreAuth details also get 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.
Following is the description of each field in the table on this pop-up:
Del checkbox: Select this checkbox and click on OK button to delete a PreAuthorization record.
Note:
A PreAuth used in an Encounter can be deleted without any validations.
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 the PreAuth rows that were saved previously. Fill PreAuth details, click on OK and open the Insurance PreAuthorizations popup again to find this icon for a newly saved record. This icon invokes a popup that displays Order Details to which PreAuth is associated along with its Usage History.
Note:
Along with type, the Usage History also presents the status of respective types such as Appointment - Completed, Claim - Billed etc.
Charge Code: Clicking the search icon next to the Charge Code field icon invokes CPT/HCPC Search popup through which the charge codes for a treatment can be selected for which PreAuth Number has been issued. This CPT/HCPC Search is powered by IMO. If a PreAuth Number with charge code is associated with a claim, the system expects that charge code to be billed on that claim; else that PreAuth No. is removed from the Charges Table of 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 in each row. Pre Auth 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 From Date is not entered for a PreAuth record, a validation message which reads ‘Please enter ‘From Date’’ stops the user from saving the record. From Date can either be selected from the calendar icon placed on the right side beside this field or can be manually entered in MM-DD-YYYY format.
Upto Date: Refers to the date upto 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. 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 availed 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 gets invoked on clicking the PreAuth hyperlink on the Appointment Schedule, hence the same cannot be associated with a claim on the Edit Claims screen.
The Visits field can be later edited from this ‘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 use of this PreAuth in earlier encounters before making entry of PreAuth in this table and hence not tracked in used count. If a value is not entered in this field before saving a record, the default value for it is shown as 0.
Comments: Enter comments related to the PreAuth record, if any. This field is not mandatory and hence can be left empty. This field supports alphanumeric and special characters and has a character limit of 255.
Closed checkbox: Check this checkbox and click on OK to stop further use of this PreAuth No. record. The checkbox once checked can later be unchecked without any validations.
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 2 scenarios:
- When initially used: While defining the PreAuth in this table, when the Initial Used field is populated with some number less than or equal to the number in Visits field, the Initial Used count gets added to this Used field.
- When Encounter starts (i.e Appointment is marked Arrived): For an associated PreAuth No. to an appointment, the Appt count is decreased by 1 and Used count is increased by 1 on starting an encounter for a Patient.
Later, the same PreAuth gets associated with a claim created by closing the same encounter.
This PreAuth is sent with billed claim information.
Till the claim is billed, the PreAuth number associated to it can be removed, resulting in reversal of Used count.
In other words, Used count of a PreAuth is the sum total of PreAuths Initially Used and number of Appointments with associated PreAuths marked as "Arrived" to start an encounter with the association not removed till the claim is billed.
Bal: This column displays the number of approved visits left with a Patient where the PreAuth Number can be used. Values cannot be manually entered in this field. This field is auto populated when values in Visits and Initial Used fields are present. When Visits and Initial Used count is not specified, this field auto populates null (0) value.
Note:
- 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 PreAuth popup is invoked from 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 on this button, Insurance PreAuthorization History popup gets invoked.