AH154checklist4
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Plaza College *
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AH154
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Industrial Engineering
Date
Dec 6, 2023
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docx
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AH154
Insurance Preauthorization Referral Process Checklist
Revised: Fall, 2023
PLAZA COLLEGE
Checklist 4: Insurance Preauthorization Referral Process VIII.P.3. Obtain precertification or preauthorization, including documentation (BL3) Name: Chelsea Albrechtsen Date: 10/10/2023 Instructions
: Please complete the assignment by reading the scenario and completing the referral form with all required information to arrange specialty care for the patient. Please be sure to delete lines on the referral form before you type the information in designated fields of the form. You need to review the rubric before submitting the completed assignment.
Task
: Dr. David Wang is referring patient, John James to Dr. Steven Warren, gastroenterologist. You need to complete the referral form based on information you received from the insurance company when arranging for the patient’s referral to Dr. Warren. Please answer the questions that follow the information for the patient, Dr. Wang and Dr. Warren. You are required to use complete, well-structured sentences, typed in Times New Roman, size 12 font, and upload as a separate word document.
Objective
:
Identify utilization review principles, including precertification and preauthorization (BL3)
Explain processes for verification of eligibility for services, including copying patients’ insurance cards, reviewing preauthorization requirements and exclusions from third-party sources (BL3)
Standards: Students must complete the assignment satisfactorily by achieving a minimum score of 74%. The time approximate for completion of this assignment is 1.5 hours.
Assessment
Points
List steps needed for preauthorization
________/15
Identify various ways to arrange preauthorization and explain which is best
________/15
Explain the purpose for preauthorization
________/15
Discuss why Primary Care Physicians are called Gatekeepers
________/15
Complete all required fields on Referral Form with Authorized Signature ________/20
Use correct grammar, spelling, punctuation, and formatting
________/10
Timely submission of completed assignment
________/10
Total Points:
________/100
Repeat:
__________
2
nd
Attempt: ________ ( /84%) 3
rd
Attempt: _________ ( /74%)
Instructor: _______________________________
Date: ________________
1
AH154
Insurance Preauthorization Referral Process Checklist
Revised: Fall, 2023
Patient Information
:
Insurance Information
:
John James
Supreme Health Plan, SHP
350 Court Street, #B12
ID#AB109713JJ/Grp#AB37BJ2
Brooklyn, NY 11215
HMO Plan
Cell: 917-655-4312; Email:johnjames1919@gmail.com
Referrals Required
DOB: 1/9/1980
#800-200-3000
SS#345-00-9876
Primary Care Physician:
Specialist Information:
David Wang, MD, NPI#3334090887
Steven Warren, MD, NPI#0908765433
255 Park Avenue, Suite 2D
1300 York Avenue, Suite 1122
New York, NY 10020
New York, NY 10021
#212-555-3212
#212-505-2020
Fax#212-555-3200
Fax#212-505-2000
Email:dwangmd@pcp.com
Email: stevenwarrenmd@cornell.edu
I.
Preauthorization Received from SHP Insurance: Patient, John James, was authorized to see Dr. Warren for evaluation and treatment of Reflux with Esophagitis, K21.0.
This authorization must be used within 30 days and extends from 6/15/23 to 12/30/23. The referral covers initial consultation, and 6 follow-up visits for treatment. The authorization number given is: EA200956780.
1.
What steps are needed to arrange preauthorization from the insurance company? To arrange preauthorization from the insurance company, it is best to be specific as possible about the planned procedure when exchanging information with a payer, collect and have available all the diagnosis information related to the procedure, including any pertinent history, and speak with the provider and then request preauthorization for all procedures that may potentially be used to treat the patient. 2.
What ways can this be done? Which way is preferred? Why?
Preauthorizations can be done over the phone, email, fax or electronically. Electronically is most preferred because of the efficiency and speed. 3.
Why is preauthorization needed from the insurance company for specific services?
Preauthorization is required from the insurance company to ensure of medical necessity.
4.
Why are primary care physicians referred to as gatekeepers?
Primary care physicians are referred to as gatekeepers because they make medical decisions based on their patient’s needs. Whether the PCP feels they can treat the patient or if they need to be referred to a specialist is the PCP’s decision. II.
Completion of Referral Form (Separate Document).
2
AH154
Insurance Preauthorization Referral Process Checklist
Revised: Fall, 2023
3
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