Step-by-step guide for prior authorization

Step 1: Check client eligibility

Log into ProviderOne to determine if your client is eligible for the service(s) or treatment(s) you wish to provide. Learn how using our Successful eligibility checks using ProviderOne fact sheet.

Step 2: Determine if a code or service requires prior authorization

Use our provider billing guides and fee schedules to review policy and find out whether a code or service requires prior authorization.

National Correct Coding Initiative (NCCI)

HCA's authorization services do not consider National Correct Coding Initiative (NCCI) guidelines when processing a request. Make sure your office checks the NCCI guidelines prior to submission.

Important

Inadvertently approved authorizations do not guarantee claims payment.

For questions about NCCI please refer to The National Correct Coding Initiative in Medicaid.

How?

On the provider billing guides and fee schedules webpage:

1. Find the program or service that corresponds to the service(s) or item. (Programs and services are listed in alphabetical order.)
2. Click the program or service name to expand the listing. Here you will find billing guides, fee schedules, preferred drug list (PDL), and expedited authorization codes and criteria for that program or service.
3. Open the appropriate billing guide, fee schedule and/or other resources based on the date of service to search for the code, service or drug.

Billing guide/fee schedule quick links

The following is a shortened list of regularly used billing guides and fee schedules.

• Complex Rehabilitation Technology (CRT)
  Note: All codes on this fee schedule require prior authorization
• Dental Program
• Medical equipment (ME)
• Orthodontic services
• Physician-related/professional services
• Prescription Drug Program

For a complete list, visit our provider billing guides and fee schedules webpage.

Step 3: Find and complete forms

Services or items requiring prior authorization must be submitted on the General Information for Authorization (HCA13-835). For drugs submitted through the pharmacy point of sale (POS) system the Pharmacy Information Authorization (HCA13-835A). Each individual service or item may require additional forms. View a list of all prior authorization forms.

Commonly used forms

One of the following forms is required to initiate the prior authorization process.

• General Information for Authorization (HCA 13-835)
• Pharmacy Information Authorization (HCA 13-835A)

Step 4: Submit a PA request

By direct data entry (DDE) in the ProviderOne portal

Providers can direct data enter authorization requests directly into the ProviderOne System. This feature includes the ability to attach records, color photos, and x-rays. Upon successful submission, a provider will receive a 9-digit reference number; the reference number is verification that the agency has received your request. Providers must not bill or perform a procedure(s) until the agency has provided written approval. This new function does not change the way the agency processes prior authorization requests, the agency will still process requests in the order received. Please ensure that when submitting a prior authorization request that the required documentation is included along with a fax number. See the self-service training resources below:

• DDE authorization for dental providers
• DDE authorization for medical providers
• DDE authorization for ME providers

By fax

Complete the General Information for Authorization (HCA 13-835) with all supporting documentation and fax it to: 1-866-668-1214.

For drugs submitted through the pharmacy point-of-sale (POS) system, complete the Pharmacy Information Authorization (HCA 13-835A) and fax to 1- 833-991-0704.

Submit x-rays or photos (if required)

Fax submissions

Use FastAttach^TM services provided by Vyne Dental (formerly NEA).

1. If you are not already registered, register at reg.nea-fast.com. For more information contact: 1-800-782-5150, ext. 1.
2. Fax your request to the agency and indicate the FastAttach# in the NEA #18 field on the PA request form.

There is a cost associated which will be explained by Vyne Dental.

Submit supporting documentation to an existing authorization

For general PA requests

use the following cover sheet when submitting supporting documents to an already existing authorization: For example, when responding to a pend for additional information, or an existing approved authorization requires a billing code or NPI update.

• Barcode cover sheet for general PA requests

For step-by-step instructions

View our guide for adding supporting documents to an existing request in pend or approve/hold status.

For drugs submitted through the pharmacy point-of-sale (POS) system

A barcode coversheet is not required. Submit supporting documentation by:

• If supporting documentation was requested by HCA on a drug or drug class specific form, fax the form as the first page followed by the supporting documentation; OR
• If HCA did not fax a specific form, fax a completed Pharmacy Information Authorization (HCA 13-835A) form as the first page followed by supporting documentation.

Step 5: Check the status of an authorization or retrieve correspondence

Learn how to check authorization information in ProviderOne.

• Check the status of an authorization
• Retrieve correspondence for an authorization
• Appendix G
• Checking status through our interactive voice response (IVR) system starts on slide 24 of the Submitting Prior Authorization for Medical and Dental Services webinar presentation slide deck.

Expedited prior authorization (EPA)

The EPA process is designed to eliminate the need for written requests for prior authorization for selected services/items.

• To view a list of qualifying services, download our EPA inventory.
• For pharmacy POS expedited authorization (EA) codes, criteria and EA guidelines, see the Prescription Drug Program expedited authorization lists.

Criteria

Following certain criteria, the agency allows for use of an EPA. Criteria are explained in each of the program provider guides.

Guidelines

• The EPA number must be used when the provider bills the agency.
• Upon request, a provider must provide documentation to the agency showing how the client's condition meets all the criteria for EPA.
• A written request for prior authorization is required when a situation does not meet all the EPA criteria.
• The agency may recoup any payment made to a provider if the provider did not follow the required EPA process and if not all of the specified criteria were met.