How to Get Prior Authorization for Treatment Planned Work

 Related Training
Pre-Authorizations Recorded Class

Also called pre-authorization, prior approval, or predeterminations, some insurance plans require prior authorization for certain services before patients can receive them.  Additionally, patients may want to know the exact amount insurance will pay before consenting to treatment. 

Sensei Cloud enables you to send pre-authorizations for treatment-planned work and record the pre-authorization reference number, or you can manually add a pre-authorization reference number to a claim (without the need to create a pre-authorization claim first).

Creating and Sending Pre-Authorizations

Note: To send a pre-authorization for treatment planned work, procedures must be entered into the patient's Treatment Plan, and the patient must have a valid insurance plan associated with their account. After the procedures are performed, the reference number is included on the claim. 

To create and send pre-authorization requests for treatment-planned work:

1. From the Patient tab, select Treatment Plans. The patient's treatment plans are displayed.
2. Click the Plan Name of the desired treatment plan. The Viewing Treatment Plan window is displayed.
3. Use the checkboxes to select one or more procedures.
   
4. Under Plan Actions, click Send Pre-Auth. The Create Insurance Claim window is displayed.
5. Select the procedures to include on the claim, and click Create. Sensei Cloud creates a Pre-Auth claim and sends it to the insurance company. The Claim column for the selected procedure changes to Pre-Auth, and the claim is added to the Claims Management queue (Patient > Insurance > Claims Management or Location > Claims > Claims Management).

Note: In the event that the patient or policyholder's date of birth is missing or invalid, a message is displayed:

Click the Patient Record hyperlink to navigate to their record and update the date of birth. The claim cannot be generated until both the patient and policyholder have valid birth dates entered.

Recording Pre-Authorization Responses

After the patient's insurance company processes the pre-authorization request, they will respond with an explanation of benefits (EOB) verifying what procedures are covered, and the amount of the expected payment. This information should include a pre-authorization number.

To enter the number:

1. From the Patient tab, select Insurance > Claims Management.
   Note: You can also find the Pre-Auth claims by selecting Location > Claims > Claims Management and sorting by Type.
2. Select the claim for which the EOB was received. The Pre-Authorization Claim Summary is displayed.
   
3. Next to Pre-Authorization #, click Add Reference #. The Add Claim Pre-Authorization Reference # window is displayed.
4. Enter the number provided and click Save. The Pre-Auth Status of the claim is changed to Closed.

Note: After the pre-authorized work is performed and a claim is created, the Patient's Ledger will display two line items: one for the pre-auth claim and one for the claim requesting payment for the work.

Manually Adding a Pre-Authorization Number to a Claim

You also have the ability to manually add a pre-authorization reference number to an insurance claim from the claims interface (Patient > Insurance > Claims Management or Location > Claims > Claims Management) without having to create a pre-authorization claim from a treatment plan first. 
For instance, you may obtain an authorization number from the insurance payer via a portal, phone call, fax, etc. You can attach the number provided by the payer to a claim from the Claim Summary. The entered number is saved in both the Claim Summary and Claim Details panels.
See How to Manage Claims for a Location for more information.