Retro-Authorization Process Update
Date: 09/25/18
Heritage Health (Medicaid):
Effective October 1, 2018, in response to provider discussion and feedback, Nebraska Total Care is updating our retro-authorization request process. To support what we hope will be a more efficient retro-authorization request process, Nebraska Total Care is moving away from a retro-authorization being initiated via claim reconsideration, to a more standard method of authorization request.
To request retro-authorization as of October 1, 2018:
- Provider will submit a retro-authorization request through the standard authorization request channels (phone, fax, portal)
- Provider explicitly identifies in the submission that they are making a retro-authorization request
- Nebraska Total Care Utilization Management will receive the request and,
o Determine if it has been made timely based on plan notification of eligibility
o If the authorization request is timely, the retro authorization will be reviewed against Medical Necessity Criteria
o If the authorization request is not timely, it will be administratively non-authorized
- For retro-authorization requests received timely and reviewed for Medical Necessity an authorization determination will be made and communicated to the provider
- For retro-authorizations that are not approved upon review, appeal rights apply, and signed release to act on the member’s behalf if appealing a retro authorization applies in line with Nebraska Total Care's existing appeals policy
Nebraska Total Care will not retroactively authorize routine services except with documentation of valid circumstances.
Qualifications for Retro-Authorization/Valid Extenuating Circumstances:
- Services authorized by another payor who subsequently determined the member was not eligible for the services or was not eligible with the payer at the time the services were rendered
- Member received retro-eligibility from the Department of Health and Human Services, Division of Medicaid and Long-Term Care
- Services occurred during a transition of care period between two Heritage Health Managed Care Organizations
- Member was not capable of providing insurance information due to incapacitation
Timely filing guidelines for claims associated with services subject to retro-authorization still apply.
If you have questions, please contact Provider Relations.