Create Utilization Plans to ensure the patient's authorization details are included on the insurance claim when required. To learn more about managing authorizations, click here.
You can create a Utilization Plan from the patient's Treatment Episode or through the U/R Work Center. U/R plans can only be created after the Insurance has been added to the patient's treatment episode.
Create U/R Plan on Treatment Episode
- Select the correct Organization, then navigate to the Patients tab.
- Locate the patient and click on their name.
- Click on the U/R quick link for the treatment episode in question.
- Click Create Utilization Plan.
- Complete the Create Utilization Plan fields:
- Select the Case Manager. This defaults to the user creating the U/R plan.
- Select a Review Type from the drop-down, options include Initial Review, Concurrent Review, Peer Review Appeal: Expedited/Urgent, and Appeal.
- Select a Start Date.
- Select an End Date.
- Select the Facility the patient is attending.
- Select the Service that is being authorized.
- Select the Service Billing Profile for the service. Service Billing Profiles are the configuration sets used to build the claim. They include coding, claim type, and other settings, so it's crucial to choose the correct one.
- Select the Rendering Provider for the service.
- Select the Referring Rendering Provider for the service. This appears in Box 17b on the CMS-1500 and Box 78 on UB-04.
- Set the Referring Rendering Provider Role. This populates in Box 17a on the CMS-1500 Box 78 on UB-04.
- Choose whether you would like the Billing Provider to be the Practice or the Rendering Provider. The Rendering Provider can only be set as the Billing Provider if the Can Bill Insurance as Billing Provider toggle is enabled for the Rendering Provider profile.
- Enter the number of Units authorized.
- Note: This number does not control how many units can be billed, provided all units fall within the specified date range of the authorization. Exceeding the number of units authorized prompts a warning in the Attendance calendar but does not prevent submission. When billed units exceed authorized units, the Remaining Units column appears in red as a negative number in the UR plan.
- Set a Treatment Episode UM Follow-Up Date to proactively request additional pre-authorization.
- Select the Primary Payer. The Effective Date of the primary payer is displayed next to the payer's name in the drop-down.
- Choose the Primary Authorization Status for the primary U/R Plan.
- Authorized: The payer has approved the medical necessity of the treatment being requested and provided an authorization number.
- Denied: The payer has denied the medical necessity of the treatment being requested.
- Not Required: The payer does not review for medical necessity for this level of care. Treatments do not require authorization and the patient will receive benefits for this treatment based on medical necessity. The payer may request medical records at a later date to investigate the medical necessity of the treatment.
- Pending: A placeholder status that is used while waiting to hear back from the care manager about approval or denial of the requested treatment. Important: Claims cannot be submitted while the authorization is in this status.
- Required – Not Obtained: This is used when authorization has never been obtained. The medical necessity can be appealed at any time.
- If applicable, enter the Authorization Number for the U/R Plan.
- If the patient has a secondary insurance, select the Secondary Payer, Authorization Status and, if applicable, enter the Secondary Authorization Number.
- Notes: You can add multiple notes to the patient's U/R plan. This field is helpful for writing down authorization details when on the phone with the payer.
- Click Save.
- When working with the authorization, use the New Note link to create additional notes tracking authorization tasks. Users can delete notes they've created for 72 hours after note creation.
- Click on the Show Notes link to display all notes added to the U/R plan.
You can upload files to the Utilization Plan by clicking the + New Files button.
When adding a file, drag and drop or click the Upload button to select the file. You can associate it with any of the Payers added to the patient's treatment episode.
All uploaded files will be added to the patient's Notes and Records tab under Files.
From the U/R Work Center
You can also create the U/R plan from the Work Center.
- Open the Work Center and click on the VOB and U/R tab.
- Select the U/R tab.
- By default, this page will display all U/R plans that have you as the assigned Case Manager. Use the Filter options to display a list of patients that need U/R plans.
- Click the Create Utilization Plan link for the desired patient.
- Follow the instructions above to create the U/R plan, starting at Step 5.