Podcast
Questions and Answers
What is the primary purpose of a Predetermination review?
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?
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?
Which OP BH service is recommended for PreD?
- Occupational Therapy
- Speech Therapy
- Physical Therapy
- ABA Therapy (correct)
When should Prosthetics be reviewed for predetermination?
When should Prosthetics be reviewed for predetermination?
What type of services are eligible for Predetermination review?
What type of services are eligible for Predetermination review?
What is the first step in the Predetermination process?
What is the first step in the Predetermination process?
What should be done if the service has already been performed?
What should be done if the service has already been performed?
What is used to verify HIPAA?
What is used to verify HIPAA?
What is the purpose of the Diagnosis Selection Search tool?
What is the purpose of the Diagnosis Selection Search tool?
What is the start date for PreD reviews?
What is the start date for PreD reviews?
What is the dollar threshold for DME predeterminations for rental?
What is the dollar threshold for DME predeterminations for rental?
What happens if a service is not listed on the Code Look Up Tool?
What happens if a service is not listed on the Code Look Up Tool?
Can Predetermination review be done for ongoing services with backdating?
Can Predetermination review be done for ongoing services with backdating?
What should you not refer to for DME predeterminations?
What should you not refer to for DME predeterminations?
Which of the following groups has both P2P and Appeal rights?
Which of the following groups has both P2P and Appeal rights?
What is the role of Intake in the Predetermination process?
What is the role of Intake in the Predetermination process?
What is not eligible for PreD, regardless of cost?
What is not eligible for PreD, regardless of cost?
What should you do for Orthotics/Braces predetermination?
What should you do for Orthotics/Braces predetermination?
What should be entered if predetermination is not required?
What should be entered if predetermination is not required?
What is the next step if Predetermination is recommended?
What is the next step if Predetermination is recommended?
What should be done with a denied case until additional clinical is received?
What should be done with a denied case until additional clinical is received?
Which of the following statements is true about Predeterminations?
Which of the following statements is true about Predeterminations?
What is the Turn-Around Time (TAT) for Predeterminations?
What is the Turn-Around Time (TAT) for Predeterminations?
What can providers submit for re-consideration if a case is denied?
What can providers submit for re-consideration if a case is denied?
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
- Check the Code Look Up Tool link: http://umr-automations.uhc.com/umrcodelookup/codesearch.aspx
- If not on Code Look Up Tool, check HPDB located in CPS/Jacada.
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.
