Prior authorization requests (PARs): How to avoid potential non-affirmations

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Home ► prior authorization ► Prior authorization requests (PARs): How to avoid potential non-affirmations

Last Modified: 11/19/2024 Location: FL, PR, USVI Business: Part A, Part B

Prior authorization requests (PARs): How to avoid potential non-affirmations

When submitting a PAR, be mindful of specific guidelines relating to proper submission to avoid potential non-affirmations. Below are common issues and related recommendations from First Coast’s Prior Authorization team to assist with proper submission.

• When submitting a PAR, please ensure you are submitting only one fax coversheet. For PAR resubmissions, discard any previous fax coversheets and create a new one to submit with all the documentation to be reviewed, not just what was missing from your prior PAR. Submission of multiple coversheets will cause a delay in the review and can result in a dismissal or non-affirmation, as it breaks up the documentation into more than one request when there are multiple fax coversheets.

• Ensure the fax numbers submitted are true fax numbers. An increase in erroneous fax numbers has been noted with PARs.

• Ensure the contact person listed has a direct phone number to reach them. An increase in general provider phone numbers with the inability to reach the contact person has been identified. If the clinical reviewer has a question, it is key they be able to reach the contact person. If they are unable to do so, then a non-affirmation may result delaying the service requested.

• Only send an expedited request if a delay could seriously jeopardize the beneficiary’s life, health, or ability to regain maximum function. There has been an increase in expedited submissions which do not meet expedited criteria, and this delays reviews.

• There have been PARs received in which documentation is redacted. This is not allowed, and the case will be dismissed.

• Hospital outpatient department services only: Remember to allow up to 10 business days for reviews. As receipt volumes fluctuate, the time it takes to review will also be impacted. Best practice is to ensure you are submitting PARs at a minimum of two weeks before you would like to schedule the procedure. However, it is strongly suggested that you do not schedule or complete the procedure before the PAR decision is received. The unique tracking number (UTN) for the claim submission is valid the day the submission is reviewed and not before. Remember that prior authorization for these services is a condition of payment, and completing the procedure before the review will result in denial of payment.

• Effective for PARs received January 1, 2025, and after the decision letter will be issued within 7 calendar days

• For facet intervention reviews: Ensure you are documenting using the same pain scale for the pain level before and after the procedure, along with the percentage of relief. This is a common reason for non-affirmation for lack of documentation.

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