Utilization Reviews (Authorizations)

The Utilization Reviews section of the patient facesheet allows users to:

• Record and track insurance authorizations for the authorized Level of Care.
• Add insurance authorizations for specific services.
• List the insurance company's care manager for the patient.

Integrated Billing: Users with Integrated Billing (Kipu RCM powered by AveaOffice or CollaborateMD) have separate requirements for adding Utilization Reviews to ensure the required information transmits to the integrated billing software as intended. Please review these instructions to learn more.

Required User Roles
Users with the Super Admin or Utilization Review Internal roles can add and manage patient authorizations. Additionally, insurance company representatives with the Utilization review external role can review the chart's content pertinent to the insurance case(s) when given the required permissions. Click here to learn more.

Add Review (UR LOC) 

Add insurance authorizations, including the patient's authorized Level of Care to the Utilization Reviews section of the patient facesheet. Let's review.

1. From the Patient Information tab, scroll to the Utilization Reviews section. 
2. Click Add Review. This is the only option that allows you to assign a UR Level of Care.
3. From the Authorization window, enter the known authorization information. Fields indicated with an asterisk (*) are required.
• Authorization Date: Add the date that the authorization was acquired.
• Number of Days: Number of days or units of treatment (e.g., sessions) authorized.
• Frequency: Select from your custom options, as set up in the Utilization review frequencies section of the Patient settings tab.
• Level of Care: Assign the patient to the authorized LOC using the Level of Care drop-down. To set up custom LOCs, click here. If you choose a LOC that is billable and has been set up to populate the LOC billing provider, an additional field will appear. Select the desired provider from the drop-down. If this option is selected, when billable per diems are generated or updated, the system will compare all completed services and automatically set the billing provider if a single provider completed all the services.
  
• Start/End Dates: Date range of the authorization. The end date takes the number entered in the Number of Days field and the day checkboxes selected (if any) into consideration when calculating the end date. It will recalculate if the number of days is changed. (If none of the checkboxes are selected, it will count every day.)
• Last Coverage Date: Select this checkbox if the End Date is the same as the patient's Discharge Date (end of the episode of care).
• Authorization Number: The reference number provided by the insurance company.
• Next Review Date: The date of the next review for the patient's case.
• Insurance Payer: Select the authorizing payer, this drop-down populates with the insurances added to the patient chart (when the patient has more than one insurance on file, the active, primary insurance will appear at the top of the list).
• Hours Per Day: Enter the allowable treatment hours per day.
• # of Days Per Week: Enter the allowable number of days per week.
• Next Care Level: Select the patient's next LOC, if known. 
• Next Care Level Date: Enter the date the patient will enter the new LOC.
• Status: Use the status drop-down to track the authorization progress. Options include New, Pending, Approved, and Denied.  
• Managed/Non-managed: This drop-down is designed to be used with Integrated Billing and impacts how the authorization number appears on the Billing report. This field defaults to Managed.
• Comment: Enter any pertinent comment, for additional reference.
• Click Save authorization.
4. The authorization appears below the Utilization Reviews section. 
   • If your LOC was billable and you selected the billing provider, they will appear here as well.
5. You can add as many reviews as needed throughout the episode of care. 
6. Once the review is entered, it will display on the facesheet with the newest authorization at the top and the oldest at the end.

Copy a Review (UR LOC) 

The Copy Review feature generates a new review by duplicating the information from an existing review and modifying any relevant fields. Any reviews created through copying will be editable and include an updated authorization date, along with a Status of New. 

Service Reviews (Ancillary)

Use Service Reviews when the payer requires authorization before an ancillary charge can be added to the per diem care. To use this feature, you must be integrated with Kipu RCM powered by AveaOffice or CMD and have Services configured in your Billing Settings. Click here to learn more about Service Reviews.

Important
The Add Service review button will not appear if the patient's location has no services configured.

Adding a Care Manager

You can add a Care Manager to the patient chart. Typically, the Care Manager is the main contact for the patient case at the insurance company.

1. Click + Add Care Manager from the Utilization Reviews section.
2. Add the Care Manager's contact information.
3. Click Save care manager.
4. You can add as many care managers as needed.