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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.