CollaborateMD: Add Utilization Reviews/Authorizations

The Utilization Reviews section allows you to add insurance authorizations for the patient that will transfer to CollaborateMD with charge information. 

Note: The system does not support documenting an authorization for a secondary insurance.

Level of Care (LOC) Utilization Reviews

The LOC specified in the following section determines which codes are billed.

1. Open the patient chart. From the Information tab, scroll to the Utilization Reviews section. 
2. While there are multiple options here, click + Add Review to add a Level of Care authorization that transmits to CMD.
3. Within the Authorization window, complete the following fields (required fields are indicated with asterisks (*):
4. Number of Days: This is the number of authorized units. 
5. Level of Care: Select the insurance-authorized LOC. This field affects key areas, like the billing audit tool report, so it’s important that these are configured correctly in your settings.
6. Start Date: This date determines when billable items become covered. For example, the date of service rendered will need to fall on or after this date to be covered. If a number is entered in the Number of Days field, the End Date field will auto-populate based on the data entered in the Start Date and Number of Days fields.
7. Authorization Number: If the insurance requires an authorization number, enter it here. 
8. Status: Select a status for the authorization. Keep in mind that the billing integration only recognizes authorizations with a status of Approved or Denied. 
   • New: Use this status for new Authorizations that have not yet been approved by the payer. Any charges in this status pushed over to the Billing Report will have a Billing Alert “Service authorization is in new status on this date” and cannot be billed until the status is updated to Approved or Denied.
   • Pending: Use this status when you are waiting on something (e.g., a call back from the payer). Any charges pushed to the Billing Report will have a Billing Alert “Authorization not found” or "Service authorization is in pending status on this date," and cannot be billed until the status is updated to Approved or Denied.
   • Approved: Use this status when the payer has approved the Authorization or if the system requires an authorization on file even if not needed by the payer. When a billing (non-ancillary) charge is added for the patient, the codes associated with the Level of Care will appear on the billing report to send to CMD. 
   • Denied: When a billing (non-ancillary) charge is added, the codes associated with the Level of Care will appear on the billing report to send to CMD.
   • Not Required: Use this status when an authorization is not required. Billable items with this status follow the same behavior as items in the Approved status, as the authorization is not required. Items in this status can be transmitted.
   • Appeal: Use this status when a billing item has been denied and you are appealing the denial. The status behaves like items in the Denied status and items in this status can be transmitted.
9. Managed/Nonmanaged: Set to Managed if the authorization number should appear on the Billing report or Nonmanaged/leave unselected if the authorization number doesn’t need to appear on the report. Any authorization number added here with a status of Approved/Denied will appear in the HL7 file and integrate into CMD. 
10. Click Save Authorization.

To bill for service(s) authorized, complete a Group Session or add an Evaluation form to the patient’s chart for the LOC. The Authorization will flow into CMD once charges have been sent to CMD from the Kipu Billing Report.

Service (Ancillary) Utilization Reviews

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 have Services configured in your billing audit tool settings and a template/form set up to bill the service code.

Important
The Add Service review button will not appear if your location or patient has no services configured.

1. Open the patient chart. From the Information tab, scroll to the Utilization Reviews section. 
2. While there are multiple options here, to add a Service authorization that transmits to CMD, click + Add Service Review.
3. Within the Authorization window, complete the following fields:
4. Service: Select the authorized service. This list is configured in Settings > Billing Audit Tool > Services. 
5. Start Dates: This date determines when billable items become covered. For example, the date of service rendered will need to fall on or after this date to be covered. End date is not required.
6. Authorization Number: If the insurance requires an authorization number, enter it here. 
7. Status: Select a status for the authorization. Keep in mind that the billing integration only recognizes authorizations with a status of Approved or Denied.
   • New: Use this status for new Authorizations that have not yet been approved by the payer. Any charges in this status pushed over to the Billing Report will have a Billing Alert “Service authorization is in new status on this date” and cannot be billed until the status is updated to Approved or Denied.
   • Pending: Use this status when you are waiting on something (e.g., a call back from the payer). Any charges pushed to the Billing Report will have a Billing Alert “Authorization not found” and cannot be billed until the status is updated to Approved or Denied.
   • Approved: Use this status when the payer has approved the Authorization or if the system requires an authorization on file even if not needed by the payer. When the service charge is added from an Evaluation, the service code will appear on the billing report sent to CMD.
   • Denied: When the service charge is added from an Evaluation, the service code will appear on the billing report sent to CMD.
8. Insurance: If the patient has more than one insurance, ensure that the insurance issuing the authorization is selected from the drop-down.
9. Managed/Nonmanaged: Set to Managed if the authorization number should appear on the Billing report or Nonmanaged if the authorization number doesn’t need to appear on the report. Any authorization number added here with a status of Approved/Denied will appear in the HL7 file and integrate into CMD. 
10. Click Save Authorization.

To bill for the service(s) authorized, you’ll need to add an Evaluation to the patient’s chart that contains the same service code(s) selected from the Code drop-down. If there's a one-to-one match, meaning a single code in the Service and a single code in the Evaluation, the code will be billed to the patient. 

However, if there are two or more codes in the service and in the form, whoever is rendering the service for the patient must remember to select the applicable code for the service being provided to the patient. Because one of the two codes they can choose from is linked to the service, they are both considered an approved service that can be billed.

The Authorization will flow into CMD once charges have been sent to CMD from the Kipu Billing Report.

Modifying Authorizations

When should I create a new utilization review? 

• When the patient receives a new authorization with a new authorization number. 
• When a new Level of Care is being authorized.
• When the existing Level of Care gets extended with a new authorization number.
• When the patient transitions from one Level of Care to another e.g., Residential to Detox.

When should I modify an existing utilization review? 

• When the authorization is extended but the authorization number doesn’t change.
• When the authorization status changes, e.g., from New to Pending or Pending to Approved/Denied.
• Add continuation to the existing comment.  

Troubleshooting Authorizations

If an authorization wasn't received in CMD, complete the following checks: 

• Verify the authorization exists within the utilization review (ensure the correct Authorization type was used e.g., Add Review).
• Verify that the utilization review is set to Managed.
• Use the Billing Report (within the transmission interface as well as in the patient chart) to verify that the authorization number was included on the billed item.

One-Direction Integration

Because the integration is one-directional—meaning data only flows from the Kipu EMR to CollaborateMD—any updates made in CMD to the patient record, etc. will not transmit back into the EMR. Additionally, any of the integrated fields (e.g., subscriber address) updated solely in CMD will be overwritten with EMR data the next time the integration pulls data into CMD (when new charges are transmitted, for example). Because of this workflow, it is crucial that demographic and authorization updates are made directly in the Kipu EMR to ensure that information is not overwritten.