Entering Authorizations

Enterprise Edition offers the ability to track insurance authorizations as dictated by a patient's insurance coverage. The Authorizations component offers different approaches.

For instance, your agency may want to enter the Authorization from the payor while still expecting physicians' order frequencies to determine when visits are scheduled. In this case, the physician's order frequency determines the schedule and the corresponding Authorization will enable prompts and constraints in order to ensure the clinician maintains compliance with the insurance authorization. In another instance, an agency may want the Authorization to determine when visits are scheduled for a patient. In this case, clinicians will be able to enter narrative orders that do not contain a physician order frequency (as the Authorization will be used to populate the Schedule).

Before adding authorizations, agencies should determine the Authorization Schedule Settings, which are set-up in Master Files | Payors/Plans | Plans.

Navigate to Patients | Intake / Referral | Insurance | Authorizations tab and complete the following steps to add a new authorization:

Enterprise Edition defaults to the patient name that is currently selected. You cannot change this information here.

This defaults to the Payor / Plan Name that is selected on the Patient Insurance tab. You cannot change this information here.

Click the arrow beside this field and select one of the following options:

● Pending (default selection for new entries) - The insurance payor has been contacted requesting authorization. The care cannot wait for the approval. The agency will select a pending amount of visits or days to start care and wait authorization approval.

● Approved - When the authorization is approved, the pending authorization is changed to the approved status. The pending amount of visits/days are factored in to the total number of visits/days so the authorization contains the full amount of authorized visits.

● Canceled - If the authorization is cancelled or the insurance company changes the amount of hours or visits issuing a new authorization, the field is used to indicate cancellation along with a discontinue date. If authorization days/visits exist past the discharge date, they will be automatically cancelled on the calendar. If the insurance company approves a new authorization, cancel the existing one and create a new authorization.

● Private Duty - Private duty insurance that will not receive an Authorization number. Private duty has many different scheduling needs and therefore has its own status. If Private Duty is selected you will have access to the various frequencies to construct the calendar as needed. This is used for scheduling if no authorization is going to be requested from a payer. For example, self-pay or if a family member is paying. This status allows the schedule access without treating it as a true payer authorization.

Enter the insurance Authorization number. This field is not available unless you select Approved in Auth Status.

● If Insurance has a “Current Auth #” value and no approved Authorization exists in the Authorization screen, the “Current Auth #” in Insurance will display in the Insurance and Relationship Tab screen.

● If Insurance has a “Current Auth #” value and a Pending Authorization exists in the Authorizations screen, the “Current Auth #” in Insurance will display in the Insurance and Relationships Tab.

● If Insurance has a “Current Auth #” value and an Approved Authorization is entered in the Authorization screen, the “Current Auth #” will not display.

● If the Approved Authorization has an “Auth #” saved, the “Auth #” will display in the Insurance and Relationships Tab screen.

Enter the date in the mm/dd/yyyy format, or click and select the date from the pop-out calendar.

Enter the date in the mm/dd/yyyy format, or click and select the date from the pop-up calendar.

Enter the date in the mm/dd/yyyy format, or click and select the date from the pop-out calendar.

Enter the date in the mm/dd/yyyy format, or click and select the date from the calendar.

Click the arrow beside this field and select either Visit or Hours, depending on how you schedule visits for the patient.

● Display the name associated with the user account and the date/time you entered the authorization in the Created By field.

● Display the Frequencies By section, which requires additional information to be entered.

Click the arrow beside this field and select the frequency.

● Flat — Use to specify the number of visits/hours or duration of time as a total, and the count of all visits/hours. On Flat frequency visits the system checks if the visits are outside of the Flat authorization end date. Even if there are a number of visits/hours still in the authorization if the authorization is at the end date the visits/hours will not be authorized.

● Daily — Use to specify authorized number of days of care for visits/hours

● Weekly — Use to specify authorized number of weeks of care for visits/hours with a weekly duration.

● Monthly — Use to specify authorized number of months of care for visits/hours with a monthly duration.

● Yearly — Use to specify authorized number of years of care for visits/hours with a yearly duration.

● Global— Use to specify a period of time that is authorized. The functions is very similar to Daily frequency as the ~~time~~ period is days based, but has been repeated to fit industry terminology. Global frequency differs from Daily frequency in that it typically has an end date for the Global period specified, whereas Daily is defined by X number of days and requires no end date to be specified.

Enter the date in the mm/dd/yyyy format, or click and select the date from the calendar. This will be automatically populated using the Begin Date entered in the Authorization Information section.

Enter the date in the mm/dd/yyyy format, or click and select the date from the calendar. This will be automatically populated using the End Date entered in the Authorization Information section.

Click the arrow beside this field and select the discipline to which this frequency applies.

Enter the number of approved hours or visits necessary for this discipline.

Enter any additional notes.

6. Click

to proceed with Generating Visits from Authorizations. Visits will automatically display on the Schedule Calendar with orange shading to indicate that they are "Unassigned".

For further details regarding Authorization settings, refer to the Authorization Schedule Settings topic.

To continue entering patient information, click the Patient Insurance tab and then click

to proceed with Entering Patient Caregivers.