ProviderOne

Prior Authorization (PA)

Frequently Asked Questions (FAQs)

Last Updated 11/4/09

How will the Prior Authorization process change when ProviderOne goes live?

Is there a new form for Prior Authorization requests in ProviderOne?

What are the new requirements for Prior Authorization requests in ProviderOne?

How will we be notified of DSHS’ pre-authorization decisions?

How do we handle claims for involuntary clients, who are not Medicaid clients, with an ITA in ProviderOne?

IP Psych admissions are sometimes pre-authorized by the RSNs, before the patient obtains DSHS coverage. For example, in the case of an ITA admit where the patient has no prior DSHS coverage, how will the patient be entered into the Provider One Pre-auth system?

Q: How will the Prior Authorization process change when ProviderOne goes live?

A: The Prior Authorization process will be very similar in ProviderOne. New forms and phone numbers will take effect.  ProviderOne identifiers will be required.

· A new form will be required with each written request. The form is available now at http://www.dshs.wa.gov/pdf/ms/forms/13_835.pdf

· A new fax number will be used (available shortly before go-live).

· A new toll-free phone number and phone tree will be in place (available shortly before go-live).

· Providers may use the ProviderOne portal to check prior authorization status, after requests have been submitted.

For more information, please refer to the ProviderOne Billing and Resource Guide. A draft version is at http://hrsa.dshs.wa.gov/download/ProviderOne_Billing_and_Resource_Guide.html

Q: Is there a new form for Prior Authorization requests in ProviderOne?

A: Yes. Providers (including dental practices) may begin using the new form now (http://www.dshs.wa.gov/pdf/ms/forms/13_835.pdf) before ProviderOne goes live. Please use your MMIS ID and the client’s PIC until ProviderOne goes live. Instructions for the form and the submission cover sheet are in the ProviderOne Billing and Resource Guide, chapter on Client Eligibility, Benefit Packages, and Coverage Limits, section 4. A draft version of the Guide is at http://hrsa.dshs.wa.gov/download/ProviderOne_Billing_and_Resource_Guide.html

Q: What are the new requirements for Prior Authorization requests in ProviderOne?

A: After ProviderOne goes live, the new form will be required and new identifiers are listed in the ProviderOne Billing and Resource Guide, Appendix G:

· Your organization’s ProviderOne ID

· The service type

· The client’s ProviderOne Client ID

· NPIs for the requesting organization, the servicing provider and the referring provider

Q: How will we be notified of DSHS’ pre-authorization decisions?

A: Providers will receive a decision letter via fax.  If the provider does not provide a fax number, then the letter will be mailed to the address in their ProviderOne provider file.

Q: How do we handle claims for involuntary clients, who are not Medicaid clients, with an ITA in ProviderOne?

A: You will continue to go through the RSN to get the Client ID for an ITA client.

Q: IP Psych admissions are sometimes pre-authorized by the RSNs, before the patient obtains DSHS coverage. For example, in the case of an ITA admit where the patient has no prior DSHS coverage, how will the patient be entered into the Provider One Pre-auth system?

A: For Prior Authorization (PA) requests when the client ID is unknown  (e.g. client eligibility pending), the provider will contact DSHS. A reference PA will be built with a placeholder client ID. If the PA is approved – once the client ID is known – the provider will contact DSHS either by fax or phone with the Client ID. The PA will be updated and you will be able to bill the services approved. These instructions are documented in the new ProviderOne Billing and Resource Guide. The draft version is at http://hrsa.dshs.wa.gov/download/ProviderOne_Billing_and_Resource_Guide.html