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May 16, 2019

PRIOR AUTHORIZATION PROCESS FOR MEDICARE ADVANTAGE PLANS

Ensure all Requested Documentation is Submitted Timely to the Health Plans

Always obtain prior authorization from the health plans before accepting an admission to your skilled nursing facility (SNF) to ensure claims payment. The health plans require medical documentation as part of the prior- authorization process. Sometimes this process can be daunting, time consuming and frustrating.

The health plans can have slightly different requirements when requesting prior authorizations. These differences can be the use of forms submitted via a fax, telephonic request, case manager intervention, or electronic via their provider portal. It is important to understand these processes and requirements to improve timely turnaround in accepting an admission. Best practices include speaking with the discharge planner or case manager to understand expectations for submitting documentation and for turnaround time for the authorization.

The requirements of prior authorization can be found in the provider manual for each health plan. Most often, the best resource and opportunity for requesting prior authorization is via the health plan provider portal. For example, Florida Blue – BC/BS only accepts prior authorization requests via their Availity provider portal.

Sometimes, for various reasons, none of these options work properly or timely. If this happens please, contact me as soon as possible to assist in this process. We intervene and obtain the correct contact at the health plan regularly to assist FAHA H&S members with authorization issues.

If you have questions, please contact Dana McHugh via email or by calling her at (850) 339-2909.





RIPPED FROM THE HEADLINES

Beneficiaries Who Switch to Medicare Advantage Have Lower Medicare Spending and Use Fewer Services – In the Prior Year – Than Those Who Stay in Traditional Medicare.   Medicare Advantage plans gain beneficiaries from traditional medicare who have lower average spending and use few health services than similar beneficiaries who choose to remain in traditional Medicare, according to a new KFF analysis. Read more...

Ciena Looks to Build on Bundled Payment Success with Medicare Advantage. As the health care system continues to push skilled nursing providers in the direction of risk, the Ciena Group has relied on lessons learned from bundled payments as it looks at entering the world of Medicare Advantage. Read more...

Health plan updates

OfficeLink Updates. We are required to notify you of any change that could affect you either financially or administratively at least 90 days before the effective date of the change. This change may not be considered a change in all states. Read More...

Sunshine Health Offers Free Provider Training for Buprenorphine Waiver. Sunshine Health, in collaboration with the American Society of Addition Medicine, is pleased to offer free online provider Opioid Use Disorder (OUD) training that will qualify you for the waiver to prescribe buprenorphine. Read More...

How to Improve Patient Satisfaction and CAHPS Scores. As one of our providers, you can provide a positive experience on key aspects of their care; we have provided some examples of best practice tips to help with each section. Read More...

Copyright 2019 — Publication of FAHA H&S
Chair: Brian Robare
President/CEO: Steve Bahmer
Principal/Editor: Dana McHugh

Copyright Information: Copies of the articles and other information in this publication may be non-commercially reproduced for the purpose of educational or scientific advancement. Otherwise, no part of this publication may be reproduced or utilized in any form, or by any means, mechanical or electronic, including photocopying, microfilm and recording, or by any information storage and retrieval system, without the written permission of the managing editor. For permission to reproduce, contact the principal/editor via email or phone at (850) 999-6034. 

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