Determination letters for pre-authorizations you submit via Availity Essentials are now available on the Authorization/Referral Dashboard, making it even easier to manage your pre-authorizations.
Availity’s Electronic Authorization application checks patient benefits and whether a service is excluded from coverage or requires pre-authorization. You can quickly submit a medical pre-authorization request and supporting clinical documentation, or check the status of requests you have submitted or have been named in.
You can prepare now for upcoming pre-authorization site-of-service reviews of select joint surgeries performed in an outpatient hospital setting.
The site-of-service reviews are an extension of our Physical Medicine program with eviCore Healthcare (eviCore) and apply to groups participating in that program. Site-of-service review will not be required when the procedure will be performed in an ambulatory surgical center (ASC), a physician’s office or an emergency facility (for urgent services).
For services delivered on or after June 1, 2023, we will redirect services to ASCs when medically appropriate and geographically available. You can begin requesting review from eviCore for these services on May 26, 2023. Pre-authorization requests submitted on or before May 25, 2023, will not be reviewed for site of service and will not result in a denial because of the site of service.
Review affected codes
View the codes that will require pre-authorization in an outpatient hospital setting in the joint management site-of-service section of our pre-authorization list.
Attend a training
eviCore has scheduled several one-hour trainings about the pre-authorization process and accessing information on the eviCore website. The trainings will include a question-and-answer period.
- Wednesday, May 24, 2023, 1 p.m. (all times PT)
- Thursday, May 25, 2023, 1 p.m.
- Friday, June 2, 2023, 2 p.m.
- Wednesday, June 7, 2023, 1 p.m.
To register, choose a Joint SOC Training from the Upcoming tab. Your registration e-mail will include the session link and call-in number.
It can be hard for patients to decide where to go when they have a sudden medical situation—especially when their primary care provider is unavailable or the patient needs after-hours help.
Resources for members
Our member website has information to help members get the care they need when they need it:
- Our member FAQ includes information about virtual, in-person (including urgent care centers) and emergency care.
- The treatment cost estimator helps members compare prices of hospital stays, MRIs, surgeries, X-rays and more. It gives an estimate based on the member’s deductible and out-of-pocket maximum.
To help our members have a better understanding of their care options, our care advocates contact members who had three or more ER visits in a six-month period or who had one or more avoidable ER visits to provide information about alternative treatment options.
Resources for providers
- Find information about members’ care options, including virtual medical and behavioral health options, our 24/7 nurse line, urgent care and more.
- Learn about specialized virtual in-network behavioral health providers available to help meet members’ care needs.
- Use Availity’s Patient Cost Estimator Tool to find out how much your patient will owe in real-time after you submit an eligibility and benefits inquiry. Watch a demo and learn more about Availity’s online resources. Sign in to Availity Essentials: Help & Training>Get Trained>Catalog>Patient Cost Estimator - Training Demo.
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