Proposed Pre-certification Loops

1. Proposed Pre-certification Loops 23 Oct 06

2. New Loop Order Sets in module (e.g., abdominal MRI) Is Order Set On UBO “possible pre-auth” List?* DEERS OHI shows Insurance yes Ping DEERS OHI (270) To see if there is insurance Provider selects Order set in module no Notice to scheduling module that patient may be scheduled Notice to scheduling module “In UBO” yes no Scheduler contacts Patient to schedule study Send off 270 to check end no Patient is covered Notice to UBO with insurance POC contact information, procedure, diagnosis, etc Study done, no OHI yes 1 no 2 end

3. Pre-auth needed UBO contacts insurance 1 UBO enters in pre- Auth package name of Contact, pre-auth #, date, Comments, etc yes no UBO enters in pre-auth package name of contact, that pre-auth not needed, and date Notice to scheduling module that patient may be scheduled MTF is paid Bill is sent With necessary data Scheduler contacts Patient to schedule study Study is completed end

4. UBO further researches OHI to determine why insurer says “no” but DEERS OHI says “yes” DEERS OHI is correct UBO contacts Insurance for pre- Authorization, and Updates order package *** note: Need way for UBO To enter pre-auth after the fact. 2 yes UBO updates DEERS OHI no end * The “Possible Pre-Authorization List” would need to be a table which can be easily Updated at each MTF. This is because the terminology used with order lists (e.g., “Knee, sunset” are not standardized for all MTFs. After this is fielded, I envision TMA UBO having a tool on the UBO website where MTFs can submit “order set Descriptions and CPT/HCPCS/NDC needing pre-auth.” Periodically, these would be Worked by the MTFs.