Add Utilization Plans with Kipu RCM (Avea) Integration.

The Concurrent Reviews section allows you to add a Utilization Plan authorizing patient treatment. This is specifically for Level of Care (per diem) billing. If you need to add an authorization for an ancillary (standalone) service, click here. 

The patient chart should already include the patient's insurance and at least one diagnosis code prior to adding the authorization. You can add multiple authorizations to the patient chart as needed. 

1. Open the patient chart. Tip: Use the universal patient search feature to quickly locate the patient.
2. From the Information tab, scroll to the Concurrent Reviews section.
3. Click Manage Review. 
4. Click Create Utilization Plan.
5. Complete the Create Utilization Plan fields:
   

   	Select the Case Manager. This defaults to the user creating the U/R plan. Select a Review Type from the drop-down, options include Initial Review, Concurrent Review, Peer Review Appeal: Expedited/Urgent, and Appeal. Select a Start Date. Select an End Date. Notes: You can add multiple notes to the patient's U/R plan. This field is helpful for writing down authorization details when on the phone with the payer.
   	Select the Facility the patient is attending. Select the Service that is being authorized. Select the Service Billing Profile for the service. Service Billing Profiles are the configuration sets used to build the claim. They include coding, claim type, and other settings, so it's crucial to choose the correct one. Select the Rendering Provider for the service. This will be the provider that appears on the Billing Report/claim. Choose whether you would like the Billing Provider to be the Practice or the Rendering Provider. The Rendering Provider can only be set as the Billing Provider if the Can Bill Insurance as Billing Provider toggle is enabled for the Rendering Provider profile.
   	Enter the number of Units authorized. Note: This number does not control how many units can be billed, provided all units fall within the specified date range of the authorization. Exceeding the number of units authorized prompts a warning in the Attendance calendar but does not prevent submission. When billed units exceed authorized units, the Remaining Units column appears in red as a negative number in the UR plan. Set a Treatment Episode UM Follow-Up Date to proactively request additional pre-authorization.  Select the Primary Payer. The Effective Date of the primary payer is displayed next to the payer's name in the drop-down.
   	Choose the Primary Authorization Status for the primary U/R Plan. Authorized: The payer has approved the medical necessity of the treatment being requested and provided an authorization number. Denied: The payer has denied the medical necessity of the treatment being requested. Not Required: The payer does not review for medical necessity for this level of care. Treatments do not require authorization and the patient will receive benefits for this treatment based on medical necessity. The payer may request medical records at a later date to investigate the medical necessity of the treatment. Pending: A placeholder status that is used while waiting to hear back from the care manager about approval or denial of the requested treatment. Important: Claims cannot be submitted while the authorization is in this status. Required – Not Obtained: This is used when authorization has never been obtained. The medical necessity can be appealed at any time. If applicable, enter the Authorization Number for the U/R Plan.
   	If the patient has a secondary insurance, select the Secondary Payer, Authorization Status and, if applicable, enter the Secondary Authorization Number.

6. Click Save to create the plan.
    
7. Click Close & Refresh.
   
8. The patient's Utilization Plan appears in the Concurrent Reviews section of the patient chart. 
   
   
   • # of days: This field displays the Number of Units authorized. 
   • Level of care: This field displays the Service selected.
   • Days of the Week: This field populates based on the days selected on the Level of Care in your Kipu Patient settings.

Managing Utilization Plans

For complete information and workflow recommendations in the Kipu RCM, please see the Utilization Review Workflow article. Utilization plans can be updated in the Kipu EMR or within the RCM. Either will appropriately update or add a new plan and display it on the patient's Kipu EMR chart. 

1. To edit an existing Utilization Plan in the Kipu EMR, click Manage Review.
2. Click Edit from the end of the UR plan row. Note: Depending on your screen resolution, you may need to scroll to the window to the right. 
   
3. Make your updates and click Save. 
4. Use the Close & Refresh button to see the updates directly on the patient chart.