Predetermination Requests and Process
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Questions and Answers

What is the primary purpose of a Predetermination review?

  • To determine the cost of a service
  • To determine coverage in accordance with the summary plan document (correct)
  • To review claims after they have been processed
  • To verify the member's identity

    • What is a requirement for re-consideration documentation?

  • It must be submitted within 24 hours of denial
  • It must be new to the case and its facts (correct)
  • It must be written by a medical doctor
  • It must be previously reviewed by a clinical team

    • Which OP BH service is recommended for PreD?

  • Occupational Therapy
  • Speech Therapy
  • Physical Therapy
  • ABA Therapy (correct)

    • When should Prosthetics be reviewed for predetermination?

    <p>If over the dollar threshold</p> Signup and view all the answers

    What type of services are eligible for Predetermination review?

    <p>Outpatient and DME services</p> Signup and view all the answers

    What is the first step in the Predetermination process?

    <p>Complete a member search</p> Signup and view all the answers

    What should be done if the service has already been performed?

    <p>Request claim submission with records</p> Signup and view all the answers

    What is used to verify HIPAA?

    <p>Patient's name, DOB, and Member ID or complete address</p> Signup and view all the answers

    What is the purpose of the Diagnosis Selection Search tool?

    <p>To determine if a service is conditional on the Code Lookup Tool</p> Signup and view all the answers

    What is the start date for PreD reviews?

    <p>Next future date of service</p> Signup and view all the answers

    What is the dollar threshold for DME predeterminations for rental?

    <p>$500 per month</p> Signup and view all the answers

    What happens if a service is not listed on the Code Look Up Tool?

    <p>The staff will check HPDB located in CPS/Jacada</p> Signup and view all the answers

    Can Predetermination review be done for ongoing services with backdating?

    <p>No, Predetermination will only review services that have not taken place</p> Signup and view all the answers

    What should you not refer to for DME predeterminations?

    <p>The Code Lookup Tool</p> Signup and view all the answers

    Which of the following groups has both P2P and Appeal rights?

    <p>TRH</p> Signup and view all the answers

    What is the role of Intake in the Predetermination process?

    <p>To check if Predetermination is recommended per code look up tool and/or HPDB</p> Signup and view all the answers

    What is not eligible for PreD, regardless of cost?

    <p>A coding services</p> Signup and view all the answers

    What should you do for Orthotics/Braces predetermination?

    <p>Check the DME tab under HPDB if med nec is recommended</p> Signup and view all the answers

    What should be entered if predetermination is not required?

    <p>Prior Auth/PreD Not Required member note</p> Signup and view all the answers

    What is the next step if Predetermination is recommended?

    <p>Intake will start the case</p> Signup and view all the answers

    What should be done with a denied case until additional clinical is received?

    <p>Do not reopen and task the case</p> Signup and view all the answers

    Which of the following statements is true about Predeterminations?

    <p>Predeterminations allow re-considerations</p> Signup and view all the answers

    What is the Turn-Around Time (TAT) for Predeterminations?

    <p>15 days</p> Signup and view all the answers

    What can providers submit for re-consideration if a case is denied?

    <p>Additional clinical information</p> Signup and view all the answers

    Study Notes

    Predetermination Requests

    • Predetermination is a review of services to determine coverage in accordance with the summary plan document.
    • It's requested by the member or provider and only applies to Outpatient and DME services.

    Predetermination Process

    • Complete a member search and verify HIPAA by ensuring patient's name, DOB, and Member ID or complete address.
    • Verify benefit plan requirements based on the service required.
    • Check if prior authorization is required and begin the prior authorization request in Aerial if necessary.
    • Intake will verify if Predetermination is recommended per code look up tool and/or HPDB.

    Code Look Up Tool

    Predetermination Review

    • Predetermination will only review if the service has not taken place and will not back date for ongoing services.
    • Reconsiderations are allowed if a case is denied, and providers may submit additional clinical for review.

    TAT and Appeal Rights

    • TAT (Turn-Around-Time) is 15 days for all Predeterminations.
    • There are no appeal rights or P2P (Peer-to-Peer) requests for Predeterminations, except for TRH, WCA Groups, and Northern Arizona Healthcare.

    DME Predeterminations

    • DME predeterminations are determined by dollar threshold of 500permonthrental/500 per month rental/500permonthrental/1,500 purchase.
    • Prosthetics are reviewed if over the dollar threshold, and Orthotics/Braces check DME tab under HPDB if med nec is recommended.
    • No Predetermination is needed for any A coding regardless of cost.

    Diagnosis Selection Search Tool

    • Use the Diagnosis Selection Search tool when services are conditional on Code Lookup Tool.
    • Example: Remicade on the Code Lookup Tool when listed as Conditional.

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    Description

    Learn about predetermination requests, which determine coverage according to the summary plan document. Understand the process, including member searches, benefit verification, and prior authorization.

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