How do I manage patient authorizations for linked contracts?

Providers can’t edit authorization details for UPR linked contracts. HHAeXchange turns off editing for these contracts to protect providers from changing values that may cause rejected claims. If the payer changes any details on their HHAeXchange system, that edit is automatically shown on the provider's platform.

For UPR linked contracts, payers control patient authorization information with most fields locked, including the Billing Diagnosis Code fields. You won't see the diagnosis code table for these types of authorizations.

The Diagnosis Codes for authorizations coming from the Payer are read-only Billing Diagnosis Codes on the provider platform.

If a provider has access to the patient's clinical pages under Patient > Clinical, they can enter and manage other diagnosis codes, surgical codes, and other clinical information without affecting the information received on the authorization from the payer.

Provider Platform: Patient Authorization

This function only applies to hourly rate types. Payers can restrict entire period authorizations to prevent providers from over utilization (over-servicing the member). Guardrail settings decide how providers distribute the authorization, ensuring that units are available throughout the entire period until the scheduled end date.

Refer to the Guardrails topic for full details on this feature.

For UPR contracts, when a payer sends a placement, authorization fields are usually locked. Providers can set an authorization guardrail for the entire period of authorizations for UPR contracts. This preserves the payer’s overall authorization limit but allows the provider to subdivide the authorization period (monthly, weekly, or daily) totals and use the Additional Rules function.

When the payer sends an entire period authorization, the provider can edit the Auth Period field on the Patient Authorization page.

Patient Authorization: Editable Period Type

If the provider selects any other period type, the system moves the value from the Max Units per Period field to the read-only Max Units for Entire Auth field. The Additional Rules checkbox also becomes available to edit.

Max Units Per Period, Max Units for Entire Auth, and Additional Rules

The system requires an authorization before you can release the visits from Billing Review and bill for them.

If a payer doesn’t send an on-time authorization for a patient, you can create a TEMP authorization. This allows you to schedule visits and pay caregivers until the payer sends the authorization. The system holds visits with a TEMP authorization at billing review.

  1. Go to Patient > Authorizations/Orders.

  2. Click Add to open the Patient Authorization page.

  3. Select the UPR Linked Contract from the Contract list.

    • If disabled, the Auth Number displays as TEMP and is not editable.

    • If enabled, the Auth Number is an editable field and is blank by default.

    Patient Authorization Created by Provider

  4. Complete the required fields.

  5. Click Save.

  6. When the payer sends the official authorization, update applicable visits and bill for them. Delete the TEMP Authorization.

  7. When the payer sends the placement, accept the placement (UPR linked contract).

  8. Merge the placement with the temporary patient record and manually change the contract on the Schedule tab to the UPR linked contract.

The following are examples and recommended resolutions to handle missing Patient and/or Authorization scenarios.

Scenario

Recommended Steps

Brand New Placement with Authorization

Review and accept Pending Placement. A Patient Record with access to Internal and UPR Linked Contracts is created with an authorization.

Brand New Placement without Timely Authorization

  1. Review the Pending Placement and accept. Once accepted, a new Patient record is created with access to both Internal and UPR Linked Contracts.

  2. Create a TEMP Authorization. Refer to Create a Temporary Authorization section.

  3. Create and process visits as usual (from scheduling through payroll). Claims are held in Billing Review for TEMP Authorization.

When the official Payer Authorization is received, two authorizations now exist for the Patient.

  1. Delete the TEMP Authorization.

  2. Click Sync and Refresh in the Actions column to recalculate. The recalculation process applies the Payer Authorization to the visits. Invoices update with the Payer Authorization number and claims can be processed.

No Timely Placement or Authorization

  1. Create a new Patient record.

  2. Assign an existing UPR Linked Contract to the Patient record.

  3. Create a TEMP Authorization. Refer to Create a TEMP Authorization section.

  4. Create and process visits as usual (from scheduling through payroll). Claims are held in Billing Review for TEMP Authorization.

When the official Payer Placement and Authorization are received.

  • Issue: The contract for the Payer Placement has overlapping Start of Care dates with the contract for the newly created Patient Record.

  • Resolution: Adjust the overlapping dates, as follows:

  1. Compare the dates on the contracts for the 2 Patient records.

  2. Change the Start of Care date and Discharge date on both Contracts so that no overlap occurs. Contracts must have different period of care date ranges.

  3. Merge the records.

  4. Click Sync and Refresh in the Actions column to recalculate. The Payer Authorization is applied to all services once the nightly process completes.