Increase your preauthorization approval rates by following these simple tips.
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Create Preauthorization Requests Tips
Avoid overlapping dates for the same services.
Overlapping dates prevent automatic approvals and delay our response to you. Upon review, the new request may be denied as a duplicate if any dates overlap. The fix is easy:
When requesting preauthorization for continuing services, like home care, make sure the new “From Date” is at least one day after the end date for the approved services.
Wrong way: 11/15 – 12/15 approved; new request entered as 12/13 – 12/31.
Right way: 11/15 – 12/15 approved; new request entered as 12/16 – 12/31.
Do not click every box shown in the MCG clinical criteria, unless all truly apply.
Many MCG screens show multiple options for you to share the member’s condition or symptoms. Checking every box shown may cause the request to pend for staff review. This may result in a denial if we cannot tell what the member is experiencing, especially when conflicting criteria are selected such as picking both low and high blood pressure.
Wrong Way:
☒ Low blood pressure
☒ High blood pressure
Right Way:
☒ Low blood pressure OR ☐ Low blood pressure
☐ High blood pressure ☒ High blood pressure
The fix is easy; only check the items which apply to the member’s condition or symptoms.
Inappropriate use of “no guidelines apply.”
Selecting “no guidelines apply” when a valid guideline is shown will automatically cause the case to pend delaying our response to you.
Complete the attestation.
This step needs to be completed, or the case will pend.
To see a definition, click on the link provided.
To see a definition, click on the guideline title such as “Knee Arthrotomy” shown in the example below.
Attach all relevant supporting clinical documentation.
Make sure your attachments have full clinical information and not only a cover sheet.
The clinical documentation you provide should directly support the selected MCG criteria. Alignment between the MCG criteria you select and the clinical documentation you send us is essential for timely approval and accurate decision making.