Automated Voice Response Eligibility Verification Subsystem Call Flow Manual

Section 13 – Prior Authorization Status Information

STEP 70.0 – Obtain Rendering Provider Number For Prior Authorization

“Please enter the eight-digit or ten-digit Medicaid Provider ID number that is located on the Prior Authorization request followed by the pound sign or press the pound sign if your provider number matches the provider number on the Prior Authorization request.”

If the user enters a provider number, the system performs an edit to ensure that it is eight numeric digits. If the provider number fails this edit, the system prompts the user for a provider number with the following message:

“Invalid provider number (PROVIDER-NUMBER). Please re-enter.”

If the user enters a valid provider number, the system continues the call flow at Step 71.

STEP 71.0 – Obtain Member Number For Prior Authorization

“Please enter the ten-digit-Medicaid Member number followed by the pound sign.”

The system edits the Member number for ten numeric digits. If the user entered a Member number in an invalid format, the system replies:

“That entry is not valid. Please enter the ten-digit-Medicaid Member number.”

If the user enters a valid Member ID, the system will continue at Step 72.0.

STEP 72.0 – DOS For Prior Authorization

“Please enter the eight digit date-of-service in month, day, century, year format followed by the pound sign, or enter a pound sign only for today's date.”

The user must enter the date-of-service in a MMDDCCYY format. The system edits the date to ensure it is in the correct format and is a valid date. If the date-of-service is not a valid date, the system informs the user:

“That date is not valid. For example, July 1, 1995 would be entered as zero seven, zero one, nineteen, ninety five. Please enter the eight digit date-of-service in a month, day, century, year format.”

The date must be no greater that one-year-old. If the date-of-service is too old, the system informs the user:

“We are unable to process dates beyond (CURRENT-DATE - 365). Please enter the eight digit date-of-service in a month, day, century, year format.”

Once the user enters a valid date of service, the system resumes the call flow at Step 73.0.

STEP 73.0 – Prior Authorization Host Transaction

Since the prior authorization information resides at the host, the system sends a transaction to the host to request service limitations information. In some cases, there may be a slight delay while the system waits for the information to return from the host, so the system informs the user with the message:

“Please wait while the requested information is retrieved.”

The voice response system will provide up to 5 prior authorizations per Member at a time. The system first checks to determine if the member is on the member eligibility file. If the member is not found on the eligibility file then continues the call flow at Step 73.0. The system next checks the response received from the host to determine whether or not the Member has prior authorization information. If the Member does not have a prior authorization, the system continues the call flow at Step 75.0. If the Member has at least one prior authorization, the system continues the call flow at Step 76.0

STEP 74.0 – Member Not On File For Prior Authorization

“Member number (MEMBER-ID) is not on file.”

The call flow is continued at Step 76.0 for Prior Authorization Continue Menu.

STEP 75.0 – No Prior Authorization Found For Member

“Our files show no prior authorizations based on date-of-service (DATE-OF-SERVICE) and member (MEMBER-ID).”

The call flow is continued at Step 77.0 For Prior Authorization Continue Menu.

STEP 76.0 –Prior Authorization Information Response

“Prior authorization number (PA-NUM) for from procedure code (FROM-PROC-CODE) and to procedure code (TO_PROC_CODE) and modifier (PROC-CODE-MODIFIER) for begin date (PA-BEGIN-DATE) and end date (PA-END-DATE) is (approved/denied/pended/used/voided).”

If the to procedure code is blank the system will only give the from procedure code. The modifier information will only be spoken if present. If the system has spoken information for the last or only prior authorization, the system continues the call flow at Step 77.0 for Prior Authorization Continue Menu.

If the system has information for more prior authorizations, it pauses to give the user a chance to record the information from the last response. The system then provides the user with the following options:

“To hear more prior authorization information, press 1. For assistance from a Customer Service representative, press 0. To skip the remaining prior authorization information, press 2.”

If the user presses 1, the system resumes the call flow at step 76.0. If the user presses 0, the call is transferred to Customer Service representative. If the user presses 2, the system resumes the call flow at Step 77.0 for Prior Authorization Continue Menu.

STEP 77.0 – Prior Authorization Continue Menu

“To inquire on another Member’s Prior Authorization information, press 3. To return to the main menu, press star 99 . For assistance from a Customer Service representative, press 0. If this concludes your call, you may hang up.”