Date Last Revised: 4/26/2019 2:10:52 PM4/26/2019 4/26/2019 2:10:00 PM

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Manage Authorizations and Certifications Gather benefit information ................................................................................................................................. 2

Find diagnosis and procedure information for the payor ................................................................................... 3

Mark an auth/cert as approved ........................................................................................................................... 4

Mark an auth/cert as not needed ........................................................................................................................ 5

Mark an auth/cert as needing clinical review...................................................................................................... 5

Mark an auth/cert as denied ............................................................................................................................... 6

Mark an auth/cert as not ready for authorization .............................................................................................. 6

Create an unlinked authorization ........................................................................................................................ 8

Link an authorization to an admission ................................................................................................................. 8

Leave a note for other staff ................................................................................................................................. 9

Date Last Revised: 4/26/2019 2:10:52 PM4/26/2019 4/26/2019 2:10:00 PM

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Gather benefit information 1. Contact the payor or intermediary agency.

Jump to a payor's website: Click to go to your reporting homepage and click a payor in the Links

section.

2. From the workqueue, select the account you are working on and click Benefit Collection under more.

3. Click a coverage name in the form navigator to open that section.

4. Complete the coverage benefit information, including entering yourself as the user who checks the

benefits and who you checked them with.

5. In the Benefits Per Service Type section, enter service type-specific information.

Date Last Revised: 4/26/2019 2:10:52 PM4/26/2019 4/26/2019 2:10:00 PM

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6. If more than one service type applies (such as an ED visit that became a specialty admission), click Add

a Service Type and enter details for the other service type.

7. Click Close, then click Verify benefits for this coverage. 8. If the patient has another coverage, collect that information in the same way. 9. If the patient owes money for the encounter, click Pre-Payment and record what the patient owes.

10. If you need to remind yourself or alert others about something related to the benefits, click Notes to

create a note. Anyone who enters the Benefit Collection activity for this encounter sees the note.

Jump to Auth/Cert: With the coverage section closed, click the Pre-cert status link in the section.

If you don't see the link, go back to the workqueue and click Auth/Cert.

Find diagnosis and procedure information for the payor While talking to the payor or intermediary, you can get information about the visit in the following places:

After double-clicking the patient in your workqueue, the subscriber information appears at the bottom right of the screen on the Coverage Information form.

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The expected admission date and time, diagnosis, and procedure appear in the table at the top of the

Auth/Cert activity.

The treatment team is listed in the chart. Click Open Chart and scroll down to the Treatment Team

section.

Refer to the Mark an auth/cert as not ready for authorization section of this guide if the payor

requests additional clinical information.

Mark an auth/cert as approved If the payor approves authorization or pre-certification:

1. From the coverage-specific form in Auth/Cert, choose the applicable Approved status in the Pre-cert status field.

2. In the Authorization number field, enter the number from the payor. 3. In the Authorized from and Authorized to fields, enter the dates for which the authorization is valid.

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4. In the Date received field, enter "t" for today's date. Your name appears automatically in the Receiving user field.

Mark an auth/cert as not needed If the payor doesn't require authorization or pre-certification for the visit:

1. From the coverage-specific form in Auth/Cert, choose the applicable Not Needed status in the Pre-cert status field.

2. If the patient has another coverage, go to the coverage's form and contact that payor or the intermediary. Gather benefit and authorization information as you did for the primary coverage.

3. If the patient doesn't have another coverage, click Accept. The system removes the visit from your workqueue automatically.

Mark an auth/cert as needing clinical review When the payor requests a clinical review before authorizing the visit:

1. From the coverage-specific form in Auth/Cert, type "Clinicals Requested" in the Pre-cert status field. 2. Click Accept. The visit now appears on a different workqueue for a case manager to work on.

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Refer to the Leave a note for other staff section for information on leaving notes for other staff.

Mark an auth/cert as denied When a payor declines to authorize or pre-certify all or part of a visit:

1. From the coverage-specific form in Auth/Cert, type "Denied" in the Pre-cert status field. 2. If the patient has another coverage, go to that coverage form and repeat the authorization process. 3. If the patient doesn't have any other coverage, click Accept. The visit is removed from your workqueue

and appears in a financial counselor's workqueue for follow-up.

Refer to the Leave a note for other staff section for information on leaving notes for other staff.

Mark an auth/cert as not ready for authorization When there isn't enough clinical information about a visit yet, you might need to wait before contacting the payor. If this happens:

1. From the coverage-specific form in Auth/Cert, type "Pending" in the Pre-cert status field. 2. Click Accept. The visit stays in your workqueue, so you can check on the clinical information later.

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If you don't have enough clinical information about a visit to authorize it, you can defer it. Deferring

temporarily removes the visit from your workqueue.

Refer to the Leave a note for other staff section for information on leaving notes for other staff.

Create an unlinked authorization Sometimes you might need to create an authorization for a patient before the appropriate encounter is created. For example, a referring clinic might be responsible for initiating authorization on an upcoming surgery before the surgical case is created. To create an auth/cert that is not linked to an encounter, use the Auth/Cert List.

1. From Patient Station, click Auth/Cert List.

2. Click New.

3. Beginning on the form with the coverage name, enter the auth/cert information. 4. When the auth/cert is complete, click Accept.

Link an authorization to an admission Authorizations are typically automatically attached to the appropriate hospital visit. Occasionally, a patient has an existing authorization that is not linked to the hospital visit. When this happens, you see the Auth/Cert Linkage activity, which opens automatically when you click Auth/Cert from a workqueue. You can also open

Auth/Cert Linkage from Registration by clicking Auth/Cert Linkage. If you attempt to create a new auth/cert for a patient with an existing unlinked auth/cert, the system prompts you to jump to Auth/Cert Linkage and review the existing auth/cert.

To link an unlinked authorization to an admission:

1. In Auth/Cert Linkage, select an authorization and look at the diagnosis, date, and other information.

2. Review each authorization until you find the correct one. 3. Select the correct authorization and click Assign. The authorization is linked to the hospital visit and

the hospital account. (If none of the authorizations are correct, click New.) 4. Click Edit to work with the authorization.

Leave a note for other staff When other staff need to know information about an auth/cert, leave a note. Case managers, financial counselors, and utilization review staff can see these notes from the Auth/Cert activity. Billers can see these notes from the Account History activity in Account Maintenance.

Notes are also generated automatically based on certain actions, such as changes to coverage information.

1. From Auth/Cert, click Notes. 2. Select the type of note you're creating. 3. Enter your note text.

Click to insert a commonly-used block of text.

4. In the Summary field, enter a few words to help other users skimming through a list of notes. 5. Click Accept Note. The note is added to that patient's list of notes.