How to ensure quicker, more accurate Elective Inpatient Admission authorization reviews

When submitting an authorization request for an Elective Inpatient Admission, make sure the requested service procedure and CPT codes match the clinical records provided. This will allow our teams to review your request quicker and with a lower likelihood of denial.

What happens if we receive an incorrect code?

When our teams receive the wrong codes on authorization requests, we follow this process:

Step 1: Make one attempt to reach out via GuidingCare message, phone call or fax to request proper clinical records to complete the review and make an accurate decision.
Step 2: If this outreach isn’t successful, we’ll deny the authorization because the requested service is unrelated to the clinical records.

What should you do if you requested an incorrect code?

For Pending authorizations (you haven’t received a decision yet):

Withdraw the authorization request. For detailed instructions, see page 193 in the GuidingCare manual. Access the manual by logging into prism, clicking Authorizations then Request an auth. From there, click Auth request help page. You’ll be able to download the manual there.

Out-of-network providers only: Submit your original Medical Authorization fax form requesting to withdraw the authorization.
Resubmit a new authorization request via GuidingCare with the proper service procedure and CPT codes and ensure the clinical records match the request.

Out-of-network providers only: Submit new authorization request via fax using the appropriate Medical Authorization form and ensure the clinical records match the request.

For authorizations Denied due to submitting the wrong code:

Resubmit a new authorization request via GuidingCare with the proper service procedure and CPT codes and ensure the clinical records match the request.

Out-of-network providers only: Submit new authorization request via fax using the appropriate Medical Authorization form and ensure the clinical records match the request.