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Medicaid Management Information Systems Maine Integrated Health Management Solution


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5.2Authorization Submission


      1. Once you are logged in as a Trading Partner, click on the Authorization Submission link. The Submit Prior Authorization– Find Member screen will populate. Verify that the Select Billing Provider information (above the Find Member tab) is correct. If there is more than one Billing Provider associated with the Trading Partner ID, click the drop-down menu to select the proper Billing Provider from the pre-determined list. See Figure 5-4: Billing Provider.

Figure 5 4: Billing Provider



      1. Once the Billing Provider is selected, the Member must be identified. To search for a member, at least two (2) of the four (4) available member search criteria fields must be filled for a successful member search:

  • Member ID (e.g. 00000000A)

  • Name (Last and First)

  • The Last Name and First Name count as one search criterion.

    • On the search screen, enter the last name in the first field provided and the first name in the second field, as shown in Figure 5-5: Member Search.

    • Names must match exactly for the first five (5) letters of the last name and the first three (3) letters of the first name.

HINT: For example, Jane Example-Member could be entered as Examp for the last name and Jan as the first name.

  • Date of Birth (e.g. MM/DD/YYYY)

  • Social Security Number (SSN)- should be entered without any dashes.

Figure 5 5: Member Search



      1. Select the Submit button to perform your search.

NOTE: If no match is found, change your search criteria. For example, use the MaineCare ID and member Date of Birth. If no match is found, or to start your search over, select the Reset button to clear all the values entered in the Find Member search fields.

      1. The search results are returned under the Find Member Results tab, as shown in Figure 5-6: Member Search Results. The search may result in a list of multiple members. Using the member’s criteria, identify the correct member. The member information that will be displayed is:

          • Name

          • Gender

          • Date of Birth

          • Member ID

      2. Select the radio button next to the member name to select the member.

      3. Click the Continue button to begin the authorization submission process.

Figure 5 6: Member Search Results



      1. Go to Section 6: Submit Prior Authorization section to complete the PA submission.


6.Submit Prior Authorization


After selecting the member, the Submit Prior Authorization– Authorization Detail screen will populate, as shown in Figure 6-1: PA Detail Screen. There are seven (7) tabs associated with this screen:

  • Member Information

  • Authorization Information

  • Rendering Provider

  • Diagnosis

  • Services

  • Miscellaneous Information

  • Notes

NOTE: Some of the fields have been pre-populated with the member and provider information based on the member you have selected and the provider entering the authorization.

NOTE: Input fields with a red asterisk (*) are required. An error message will be displayed if these values are left blank.

Figure 6 3: PA Detail Screen



      1. Complete the Authorization Information tab as outlined in Table 1: Authorization Information Tab.

Table 1: Authorization Information Tab

Field Name

Helpful Information

Authorization Type

Required field. Click the drop-down menu and make a selection from a pre-determined list.

If you are unsure about the Authorization Type, contact Provider Services at 1-866-690-5585.



Pay-To/Billing Provider

Pre-populated. This field will be system-generated based on the trading partner account submitting the authorization.

Requesting Provider

Required field. Click the drop-down menu and make a selection from a pre-determined list. This includes all affiliations associated with the trading partner account submitting the authorization. Select the appropriate one.

Requested Length of Stay

Optional field. Some examples for when this field would be used are: Inpatient Hospital stays, Nursing Homes, Boarding Homes and ICF-IID.

Start Date

Required field. Requests for non-emergency services must be submitted to MaineCare at least 30 calendar days before the appointment. Requests must be approved before services are provided.

End Date

Required field. The end date cannot extend beyond one (1) year.



      1. Complete the Rendering Provider section. The Rendering Provider or Group field is required. The Rendering Provider or Group should reflect the provider that is rendering the service associated with the prior authorization. To enter a value in the Rendering Provider or Group field, select the Search icon as shown in Figure 6-2: Rendering Provider Search.

NOTE: The system automatically defaults to the provider that is requesting the service.

Figure 6 4: Rendering Provider Search



      1. A provider search screen will populate, as shown in Figure 6-3: Provider Search Results– With Rendering Providers.

      2. Complete one or more of the provider search fields.

      3. Click the Search button. The search results are returned at the bottom of the screen under the Search Results tab as shown in Figure 6-3: Provider Search Results– With Rendering Providers.

      4. To make a selection, click on the radio button next to the correct rendering provider, as shown in Figure 6-3: Provider Search Results– With Rendering Providers or the Pay-To provider as shown in Figure 6-4: Provider Search- Without Rendering Providers and select the Continue button. Clicking Cancel closes the Provider Search screen and returns to the authorization screen.

      5. In the Pay To/Billing Provider field, if the Rendering Provider (RP) is affiliated to more than one (1) Pay-To Provider, the correct Pay-To/Billing Provider must be selected from the drop-down menu. See Figure 6-2: Rendering Provider Search.

      6. Select the correct Service Location from the drop-down menu, as shown in Figure 6-2: Rendering Provider Search.

Figure 6 5: Provider Search Results – With Rendering Providers



Figure 6 6: Provider Search - Without Rendering Providers



      1. The Diagnosis section must be completed to submit the PA. It is possible for the member to have multiple diagnoses. There are three (3) fields in the diagnosis section; these fields are described in Table 2: Diagnosis Fields. If the user already knows the Diagnosis Code, he or she can type in the code and press tab.

Table 2: Diagnosis Fields

Field Name

Helpful Information

Seq #

The Seq # will increase as each line is added. Up to 12 diagnosis codes may be entered. To add a new line, press the Tab key at the end of the last line and a new line will appear.

Code

This user is responsible for populating the code field.

Description

The description will appear once the code is entered and the tab key is pressed.

Only one primary diagnosis can be entered for each prior authorization. The first line entered is the primary diagnosis and must be closely related to the procedure. Any additional diagnosis entered will be considered a secondary diagnosis.



NOTE: Always tab through fields on a single line to ensure proper completion.

      1. To search for a Diagnosis Code, click within the code box and then click the Search icon, as shown in Figure 6-5: Search for Diagnosis Code.

Figure 6 7: Search for Diagnosis Code



      1. A new search window will open, as shown in Figure 6-6: Diagnosis Search. To search for a specific code, enter part of its description in the field provided.

      2. Click the Search button to retrieve a list of results.

Figure 6 8: Diagnosis Search



NOTE: MIHMS will match exactly the sequence of characters entered in the search criteria. For example: if nothing is found for “Sleep Disorder” try using only “sleep." Conversely, using just the word “disorder” may be too broad and result in a longer list. To start over, click Reset to clear the Description field.

      1. The search will return a list of Code IDs, Descriptions, Effective and Term Dates and ICD Versions. Click any Code ID link to populate the Code ID to the Diagnosis section, as shown in Figure 6-7: Diagnosis Search Results.

Figure 6 9: Diagnosis Search Results



      1. Once the Code ID is displayed, tab through to auto-populate the description, as shown in Figure 6-8: Diagnosis Description. A new line will be presented if additional codes need to be entered. Up to 12 Diagnosis Codes can be added by tabbing to the next line.

Figure 6 10: Diagnosis Description



      1. Complete the Services section. The Service section is used to enter all of the services for which the provider is requesting prior authorization. As many as 99 service lines can be entered. The fields and links associated with this section are summarized in Table 3: Field Name and Field Description.

NOTE: Certain radiology services require PA effective March 1st, 2014. A list of these service codes is provided in Appendix A.. Submission instructions for CT and PET (radiology) codes that require PA are available in the Pathways Radiology Prior Authorization Request Guide at the link provided below:

https://mainecare.maine.gov/Provider%20Forms/Forms/Publication.aspx?RootFolder=%2fProvider%20Forms%2fAuthorizations%20Pathways&FolderCTID=&View=%7b550DD634%2d668F%2d47E9%2dB0DD%2d93CDCC1CD721%7d

Table 3: Field Name and Field Description



Field Name

Field Description



Click this icon to delete a service line.

Seq #

Pre-populated. This is a system-generated field used to number each service line added by the user.

To add a new service line, hit tab at the end of the last line and a new line will appear.



Code

This field represents the Current Procedural Terminology (CPT) or Revenue Code for the service. Enter the code in this field if known or use the Search icon link to perform a code search. See step 16 for instructions on searching for a code.

Description

Description of the service code entered for the specified service line.

DOS From/DOS To

This field is required. Enter the beginning and ending dates of the period in which the service was provided. Dates must be entered in MM/DD/CCYY format. For example, February 14th, 2008 would be entered as “02/14/2008”.

Modifiers

CPT code modifiers provide additional details regarding various services.

Units

Enter the number of times the service will be performed.



      1. To search for a Service Code, click the Search icon, as shown in Figure 6-9: Service Code Search.

Figure 6 11: Service Code Search



      1. A new search window will open, as shown in Figure 6-10: Service Code Search Window. Select the appropriate radio button to search for either a Service Code or a Revenue Code.

      2. Enter any part of the description of the code in the Description field and click the Search button.

Figure 6 12: Service Code Search Window



NOTE: MIHMS will match exactly the sequence of characters entered in the search criteria. For example: if nothing is found for “sinus surgery” try using only “sinus.” Conversely, using the word “surgery” may be too broad and result in a longer list.

      1. To start over, click the Reset button to clear the Description field.

Note: You may not have the exact service code or all the codes for services you are requesting, but a code that communicates in general terms what you are requesting.

      1. The search will return a list of Service ID Codes, Descriptions, and Effective and Term Dates as seen in Figure 6-11: Service Code Search Results. Click the Service ID Code link to return the selected Service Code to the Service Code field.

Figure 6 13: Service Code Search Results



      1. Once the code is selected, the Code will be highlighted in the code field as shown in Figure 6-12: Service Line Example. Press the tab key to the description field to auto-populate the service description and continue pressing tab to go to the next field on the service line to be completed.

Figure 6 14: Service Line Example



      1. Complete the Miscellaneous section. Enter any miscellaneous information about the member into the Miscellaneous Information section, as applicable. See Figure 6-13: Miscellaneous Information. The Accident Information box has three (3) selections:

  • Auto Accident

  • Employment

  • Other

NOTE: The Accident Date is to be filled in if any of the radio buttons are selected. Click Investigation Required, if applicable.

Figure 6 15: Miscellaneous Information



      1. The Notes section is used to enter any other comments to further support the Prior Authorization request. Click in the text box and type in supporting text.

      2. When all the information has been entered, click the Submit button to submit the authorization, as shown in Figure 6-14: Notes.

NOTE: Any errors in your application will be indicated at the top of the page in a red font and must be corrected before the authorization can be submitted.

NOTE: To ensure a faster decision of your authorization request, add the contact information (e.g. Name & Phone Number) of the person entering the authorization.

Figure 6 16: Notes


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