Billing

Prior authorizations and Visit Counter Tracking

Prior authorizations and Visit Counter Tracking help in managing the number of allowed visits for the Patient as per the Insurance company's approval. Tracking prior authorized visits will help Practices in getting timely approval for additional visits and avoiding claim denials for the lack of prior authorization.

Prior authorization obtained from the Payers can be added in the Patient Insurance section. The Prior authorization details contain Prior Authorization numbers issued by the Payer, Type, and Validity dates. This Prior auth number will be automatically filled in the CMS1500 form when a Claim gets generated for the Patient.

• Adding Prior authorization details in the 'Insurance' section
• Prior Auth Visit Counter
• Prior Authorization View
• Prior Authorization Report

Adding Prior authorization details in the 'Insurance' section

To add Prior authorization details, follow the steps given below.

1. Go to 'Patient > Patient Details > Insurance'
2. Click the '+ Insurance' button to add a new Insurance.
3. Go to the 'Prior Authorization details (Prior Auth)' section to add the Prior Authorization details. Prior Authorization can be added either for a combination of factors, such as an Allowed visit, Procedure Code, and Provider, or it can be applied to each element individually.
   
   
   1. Add Prior Authorization specific to a Provider - CharmHealth allows the user to add Prior Authorization specific to a Provider. This helps to track the Patients' visits based on a specific Provider. When a Prior Authorization gets configured for the Provider, the order of the Providers arranged in the 'Prior Authorization Provider' setting under the 'Settings > Billing-Claims - Insurance Settings' section will be followed for Prior Authorization counter calculation. The Practice can re-order the Providers as per their preferences.
      
   2. Add Prior Authorization Specific to CPT: When the Prior auth is for a specific procedure, 'CPT code' can be added. Practice can also add 'Warning Count'. When the number of allowed visits reaches the 'Warning Count', it will be shown with a special icon in the Patient Dashboard and Appointment view.
   3. Add Prior Authorization without Prior Auth # - It is used to track visits of Patient health plans without any Prior Auth number. When configuring Allowed Visits, ensure you provide the From and To dates.
4. When a Prior Authorization gets added, the system automatically maps previous visits (if any) based on the Prior Authorization’s Date Range, Procedure Code, and Provider.

Prior Auth Visit Counter

• Many times, Prior authorization can be valid for a specific number of Patient visits. In such cases, 'Number of Allowed Visits' for the Prior authorization can be configured in the 'Patient > Patient Details > Insurance' section.
• The Practice can go for approval of additional visits when the 'Available Visits' reach the 'Warning Count' based on the Patient's condition.
  

Allowed Visits are to be specified as on the current date, excluding the previous visits. Prior auth tracking starts from the day of adding the 'Allowed Visits' and gets reduced automatically when an Encounter gets created for the Patient.

Prior Authorization View

The number of visits based on prior authorizations gets tracked, and the allowed count gets reduced automatically when the Patient visits the Provider. All Prior auth details are shown in a separate icon in the Patient Dashboard and Appointment section when the visits are configured for the Patient's Prior Authorization. The icon color will change based on the 'Available Prior Authorization Count'.

Prior authorization details as shown on the Patient Dashboard

You can view the list of Encounters based on the Prior Authorization Date range, Procedure Code, and Provider. Select/unselect the visits to be considered in the Prior Authorization.

Prior authorization details in Create New Appointment view

When the available number of visits reaches the 'Warning Count', it will be shown with a special icon in the Patient Dashboard and Appointment view. Practice can go for approval for additional visits when 'Available Visits' reach the 'Warning Count' based on the Patient's condition. The icon color will change based on the 'Available Prior Authorization Count'. Refer to the screenshot below.

Prior Authorization Report

To manage all the Prior Authorizations, you can use the report under the 'Billing > Reports > Patient Reports > Patients with Prior Authorization' section that lists all the Prior authorizations added to all the Patients under the Insurance section.

This report lists all the prior authorization details configured for the Patients along with validity dates and allowed visits, available visits, Insurance ID, etc. Practice can filter prior authorizations based on the Payer, filter the ones with 'Available Visits' reached the 'Warning Count', and based on the Date Range. By clicking on the 'Insurance ID', the Patient's Insurance details can be viewed, and the Prior auth details can be updated if required.

For example, when the warning count gets configured for the Prior auth, and the Practice Members need to see all Prior authorizations that have reached the warning count to go for additional visit approvals, users can take it as given below.

When the Practice needs to group prior auth based on Available Visit, select the 'Available Visit' option under the 'Group Report By' drop-down menu. A detailed report can be seen by clicking the respective total values.