Authorizations

Information about Authorizations

Billing / Authorizations “Authorization Expired or Not Valid for Service Date”

This is most likely due to the fact that the appointment date is past the authorization end date that this appointment was originally coded with. This can occur in cases where a recurring appointment series was accidentally set up past the authorization’s end date. Another explanation is that the appointment series was scheduled to end on the same date as the authorization end date, but the authorization end date was later shortened.

Billing / Authorizations Authorization Report Showing Extra Time in the Pending Column

CentralReach’s Authorization report is a great way of tracking approved, worked, and unused clinical hours. It will show when hours have expired and when you are reaching the end of your bucket of authorized hours. You can view hours in the pending column when there are no scheduled hours.

If you are seeing additional unused time in the Pending column, please check that all appointments have been converted using the full amount of time scheduled.

  • For example, if an appointment is scheduled for two hours, but the converted timesheet is only for one hour, the authorization report will show the unused hour as pending

To remove this pending time from the report, change the duration of the appointment to match the timesheet or vice versa.

Billing / Authorizations Deleted Authorization Still Appearing on Authorization Report

If you can view a deleted authorization file in the Authorization report, this is because the codes within that authorization are either still attached to appointments (indicated by the Pending column) or timesheets (indicated by the Worked column). Clicking on the hyperlinks within these columns will direct you to their corresponding appointments and billing entries, respectively. You will also see “Deleted” next to the authorization name to display its status.

Billing / Authorizations Follow-Up Authorizations

In the “Authorizations” section of the Billing module, expired authorizations can have a “follow-up” authorization. If an authorization has expired with service codes that are exactly the same and the follow-up begins the day after one ends, there will be a “double page” icon on the right-hand side. Clicking the icon will open the follow-up authorization.

Billing / Authorizations Load Totals

Clicking the blue “Load totals” button will automatically calculate/load the totals for the authorized, worked, pending, remaining, and utilization columns.

Billing / Authorizations Monthly (Pro-rated) and Monthly (Actual Values)

In the Authorizations report, view the pro-rated total and the actual totals.

  • Pro-Rated: the system calculates the authorized amounts for you. As such, if the authorized weekly amount is set as 10 hours, the system will divide the hours by 7 to calculate the daily amount and then multiply that amount by the number of days within a month, thereby giving you the pro-rated total authorized amount in a single month.
    • (# of weekly amount / 7 days) x (# of days in a month) =  Monthly (Pro-Rated) amount
      • Example: (10 weekly hours) / 7 days) x (30 days in a month) = 42.86 hrs of pro-rated monthly authorized hours
  • Actual Values: the system calculates the authorized amount by the weekly basis. As such, if there are 30 days in a single month, with 28 days being counted as 4 weeks, the last 2 days will be calculated as another whole week, thereby causing the calculation of the authorized amount to be resulted in 5 weeks. This will cause the weekly amount of 10 hours to result in 50 hours.
    • (# of weekly amount) x (# of weeks in a month) = Monthly (Actual Values) amount
      • Example: (10 weekly hours) x (5 weeks in a month) = 50 hours of monthly actual values amount

Billing / Authorizations / Claims The Authorization Claims Settings Tab

Authorization Claim Settings allow users to specify certain fields in electronic claims. The “Authorization and Claims Settings” tab is in the Global Authorizations page tab in an authorization and contains the following optional fields: 

  • CRC EPSDT Referral: Identifies services that may be covered under specific state plans and informs insurance providers of the referral status specific to each payor. If there is a requirement to use a specific reason code, enter that code in the EPSDT field. 
    • Condition Indicator: Select the following options from the drop-down: 
      • AV – Available  
      • S2 – Under Treatment 
      • ST – New Service Requested 
      • NU – Not Used
  • CN1 Contract Information: These fields capture the contract number certain payors require when submitting claims.  
    • Contract Code Type: The contract type required for post-adjudication claims. Select the following options from the drop-down: 
      • 01 Diagnosis Related Group 
      • 02 Per Diem 
      • 03 Variable Per Diem 
      • 04 Flat 
      • 05 Capitated 
      • 06 Percent 
      • 09 Other 
    • Reference Identification: For a particular transaction set or as specified by the “Reference Identification Qualifier.” 
    • Please note, users can have both fields completed, or just the Contract Code Type. However, if the Reference Identification field is added without the Contract Code Type, the Reference Identification field will not populate in the 837 form.
  • REF – Billing Provider Secondary Identification 
    • G2 – Provider Commercial Number 
    • LU – Location Number 
    • Please note, both fields can contain values. 

When generating 837 files, “EPSDT Referral,” “Contract Type Code,” and “Reference Identification” fields in the claim details are for billers requiring a specific reason code. 

Please note: 

  • These fields will not copy over from the original claim when generating a secondary claim. 
  • If the selected billing entries are associated with more than one authorization, the retrieved values will be from the authorization related to the first billing entry.   
  • These values will be populated from the default values when submitting a claim. If there are no default values, information will be retrieved from the Global Authorization Settings.  
  • If there are no values in the Authorization Claim Settings, the Claim editor fields will be empty but are editable.  
    • For the G2 and LU fields: 
      • Values will be retrieved for the authorization. 
      • If no authorization has a value, values from the Accepted Insurance will be retrieved.  
      • If both are empty, the fields will be empty but editable.

Billing / Authorizations Tracking and Billing Primary and Secondary Insurance

For tracking and billing primary and secondary payors in CentralReach, it is recommended to:

  1. Set the primary authorization to what the client will be authorized for across both authorizations.
    • Please note, if the secondary insurance offers more authorized hours than the primary, it is up to the organization on how to enter the hours. The primary authorization should always be set to what can be controlled and handled. 
      • For example:
        • The primary payor authorizes 5 hours per week with a rate of $100 per appointment
        • The secondary payor authorizes 10 hours per week with a rate of $50 per appointment 
          • Decide to set the authorization to either 5 or 10 hours per week. If 10 hours per week is set, then decide if you can make up the difference in rates for the rest of the 5 hours per week.
  2. Schedule appointments, create timesheets, and generate claims with the primary insurance, and they will pay for their authorized hours.
  3. After all authorized hours for the primary insurance have been used and claims are still being generated, users should receive non-payment responses from the primary payor.
  4. Change the payor in the billing screen for those billing entries from the primary insurance to the secondary insurance.
    • This will update the receivables.
  5. Complete the billing process.