Patient Authorization and Uniform Allocation Details

For UPR Linked Contracts, the Patient Authorization information is controlled by the Payer and most fields are locked including the Billing Diagnosis Code fields; the Diagnosis Code table is not seen for these Authorizations.

The diagnosis codes for an Authorization coming from the Payer display as read-only in the Billing Diagnosis Code fields on the Provider platform.

If a Provider has access to the Patient’s Clinical pages under Patient > Clinical, then they can enter and manage other Diagnosis Codes, Surgical Codes, as well as other Clinical information, without affecting the information received on the Authorization from the Payer.

Create a Temporary Authorization Closed

If a Payer does not send a timely authorization for a Patient, the Provider can create a Temporary Authorization. This enables the Provider to schedule visits and pay the Caregivers until the authorization is received from the Payer.

An official Payer Authorization is required for billing; otherwise, the visits are stopped in Billing Review and cannot be billed.

To create a Temporary Authorization,

Go to Patient > Authorizations/Orders.
Click Add to open the Patient Authorization page.
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.
Complete the required fields, and then select  Save.
When the payer sends the official authorization, update applicable visits and bill for them. Delete the TEMP Authorization.
When the payer sends the placement, accept the placement (UPR linked contract).
Merge the placement with the temporary patient record and manually change the contract on the Schedule tab to the UPR linked contract.

Provider-Managed Guardrails for Entire Period Authorizations Closed

When a Payer sends a Placement, all Authorization fields are locked for UPR Contracts.; however, Providers can set an Authorization Guardrail for Entire Period type Authorizations for UPR Contracts. This preserves the Payer’s mandated overall Authorization limit while allowing a Provider more flexibility to subdivide the Authorization Period (Monthly, Biweekly, Weekly, or Daily) totals and use the Additional Rules functionality.

When an Entire Period type Authorization is sent by the Payer, the Period field becomes available for a Provider to edit on the Patient Authorization window.

If the Provider selects another Period type, then the value (number of hours) originally indicated in the Max Hours per Period field moves to the Max Hours for Entire Auth field and is unavailable to edit. When the Period type is changed, the Additional Rules checkbox also becomes available to edit. Save the authorization to generate Provider Guardrails.

When changing the Auth Period to Daily, Weekly, or Biweekly the Specific Date Type field becomes available to edit.

Solutions for TEMP Patient and/or Authorizations Closed

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	Review the Pending Placement and accept. Once accepted, a new Patient record is created with access to both Internal and UPR Linked Contracts. Create a TEMP Authorization. Refer to Create a Temporary Authorization section. 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. Delete the TEMP Authorization. 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	Create a new Patient record. Assign an existing UPR Linked Contract to the Patient record. Create a TEMP Authorization. Refer to Create a TEMP Authorization section. 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: Compare the dates on the contracts for the 2 Patient records. 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. Merge the records. Click Sync and Refresh in the Actions column to recalculate. The Payer Authorization is applied to all services once the nightly process completes.

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

Review the Pending Placement and accept. Once accepted, a new Patient record is created with access to both Internal and UPR Linked Contracts.
Create a TEMP Authorization. Refer to Create a Temporary Authorization section.
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.

Delete the TEMP Authorization.
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

Create a new Patient record.
Assign an existing UPR Linked Contract to the Patient record.
Create a TEMP Authorization. Refer to Create a TEMP Authorization section.
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:

Compare the dates on the contracts for the 2 Patient records.
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.
Merge the records.
Click Sync and Refresh in the Actions column to recalculate. The Payer Authorization is applied to all services once the nightly process completes.

Uniform Allocation of Hours for Authorization Guardrails Closed

The Uniform Allocation (Hours) field displays on the authorization when Provider Guardrails and the Uniform Allocation is enabled. The Uniform Allocation (Hours) feature allows you to divide the Provider Allocated Hours evenly to all current and future Authorization Periods on the Authorization Guardrail Breakdown table.

Select Daily in the Auth Period field to allocate Authorization Hours for specific days of the week.

All Days - Evenly divides the Authorization Hours across all days.

Example: If you enter 2 hours daily, 2 hours are allocated for each day, Monday through Sunday.
Specific Days - Allocates Authorization Hours based on the hours entered for each specific day.

Example: If you enter 2 hours for Tuesday and 1 hour for Thursday, 2 hours are allocated every Tuesday and 1 hour every Thursday during the Authorization period.

Enter the quantity in the Uniform Allocation (Hours) of hours to divide between the current and future Provider Guardrail Periods.

If you run out of allocated hours, you can send the Payer a request for more hours. After you enter the hours in the Uniform Allocation (Hours) field, select Save. The Insufficient Total Hours box displays. Select the Request more hours from payer check box, add a message, and then select Save.

Use the Reallocate Unused Hours button to allocate more hours to current and future periods(s) in the Provider Allocated (Hours/Period) field. Any additional hours are added to the Remainder field.

Current and Future periods(s) below the set Uniform Allocation (Hours) are allocated more hours, and any additional hours are added to the Remainder field.

If the Used (Hours) field does not equal the amount allocated in the Uniform Allocation (Hours) field, and the Keep Uniform Allocation for past periods when Service Authorization is recalculated button is selected on the Admin > Provider Profile, then Provider Allocated (Hours/Period) column remains equal to the Uniform Allocation (Hours) field for past periods.