Navigating the complexities of prior authorization can be a significant hurdle for healthcare providers. To ensure seamless service delivery and timely reimbursements within the Coordinated Care network, understanding and effectively utilizing the Coordinated Care Prior Auth Tool is essential. This guide provides a comprehensive overview of how to leverage this tool to streamline your administrative processes and focus on delivering exceptional patient care.
Understanding Prior Authorization with Coordinated Care
Prior authorization, often referred to as pre-authorization or pre-cert, is a process required by health plans like Coordinated Care to determine medical necessity and coverage for certain services, procedures, or medications before they are rendered. This process helps ensure that patients receive the most appropriate and cost-effective care while adhering to their benefit plan guidelines. For providers, understanding when and how to obtain prior authorization is crucial for efficient practice management and avoiding claim denials.
Within the Coordinated Care network, utilizing the Coordinated Care Prior Auth Tool is the most efficient method for determining if a service requires authorization and for initiating the request process. This tool is designed to provide quick answers and guide providers through the necessary steps.
Services Requiring Verification and Prior Authorization
While the Coordinated Care Prior Auth Tool is your primary resource, it’s helpful to understand general categories of services that typically require verification or prior authorization. Keep in mind that this is not an exhaustive list and the tool should always be consulted for specific service codes.
- Vision Services: Verification for vision services is managed by Centene Vision Services. Providers should utilize the Centene Vision Services portal or contact them directly to verify coverage and authorization requirements for vision-related services.
- Dental Services: Similarly, dental service verification is handled by Centene Dental Services. Check with Centene Dental Services for all dental prior authorization needs.
- Complex Imaging, Musculoskeletal, Pain Management, and Oncology Services: A significant range of specialized services are managed through Evolent. This includes:
- Complex Imaging: MRI, MRA, PET, and CT scans often necessitate prior authorization through Evolent.
- Musculoskeletal Services: Procedures related to the shoulder, hip, spine, and knee, particularly surgeries, usually require pre-authorization from Evolent.
- Pain Management & Spinal Cord Stimulators: Specific pain management procedures and the use of spinal cord stimulators are also managed by Evolent. It’s important to note that chiropractic services are not managed by Evolent.
- Medical Oncology & Biopharmacy Supportive Drugs: Prior authorization for medical oncology treatments and related biopharmacy supportive drugs are processed through New Century Health, which is accessed via the Evolent platform.
It is critical to remember that services provided by out-of-network providers are generally not covered without explicit prior authorization from Coordinated Care. Providers considering out-of-network referrals must secure prior authorization to ensure coverage for their patients. Coordinated Care encourages providers to join their network to simplify patient access and administrative processes. Join Our Network for more information.
Emergency Services: An Important Exception
It is vital to understand that services performed in a bona fide Emergency Department setting or for emergent transportation do NOT require prior authorization. This exception is in place to ensure that patients receive immediate and necessary medical attention in critical situations without administrative delays. However, it’s crucial to accurately classify services as emergency care when applicable to avoid unnecessary prior authorization requests.
Navigating the Prior Authorization Decision Table
To further clarify when prior authorization is needed, consider these key questions. Answering “YES” to any of these questions may indicate the need for prior authorization, and the Coordinated Care Prior Auth Tool should be consulted for definitive guidance.
| Types of Services | YES | NO |
|---|---|---|
| Are the services being performed or ordered by a non-participating provider (professionals/facilities)? | ||
| Is the member being admitted to an inpatient facility? | ||
| Are anesthesia services being rendered for dental surgeries? | ||
| Are oral surgery services being provided in the office? | ||
| Is the member receiving Gender Affirming services? |
If you answer “YES” to any of these questions, it is highly likely that prior authorization will be required. The next step is to utilize the Coordinated Care Prior Auth Tool to confirm and initiate the authorization process.
Utilizing the Coordinated Care Prior Auth Tool: A Step-by-Step Guide
The Coordinated Care Prior Auth Tool is designed to be user-friendly and efficient. Here’s how to use it effectively:
- Access the Provider Portal: The tool is accessed through the Coordinated Care provider portal. Navigate to the login page: Login Here.
- Login to Your Account: Enter your provider credentials to securely access the portal.
- Locate the Prior Authorization Section: Once logged in, find the section dedicated to prior authorizations. This may be clearly labeled as “Prior Authorizations,” “Pre-Auths,” or similar.
- Enter the Service Code: You will find a designated field to enter the CPT or HCPCS code for the service you wish to check. Enter the specific service code in this field.
- Check Requirements: After entering the code, the tool will provide immediate feedback on whether prior authorization is required for that specific service under the member’s plan.
- Submit a Prior Authorization Request (If Required): If the tool indicates that prior authorization is needed, you can typically initiate the request directly through the portal. The tool will guide you through the necessary information and documentation required for submission.
Service Code Lookup: Quick Verification
The Coordinated Care Prior Auth Tool prominently features a service code lookup function. This is designed for quick verification. Simply enter the code of the service you would like to check into the provided field within the tool. This will provide an immediate determination of whether prior authorization is necessary, saving valuable time and effort.
Submitting Your Prior Authorization Request
For services requiring pre-authorization, the Coordinated Care Prior Auth Tool seamlessly integrates with the submission process. After verifying the need for prior authorization, you can directly proceed to submit your request through the portal. Login Here [https://provider.coordinatedcarehealth.com] to access the tool and begin the submission process.
By effectively utilizing the Coordinated Care Prior Auth Tool, providers can significantly streamline the prior authorization process, reduce administrative burden, and ensure timely access to necessary care for Coordinated Care members. This ultimately contributes to improved patient outcomes and a more efficient healthcare delivery system.
