BCBSLA Authorizations Application Professional User GuideBCBSLA Authorizations Application Professional User Guide May 2016 Page 11 of 114 o Processed – the episode is in a “Closed”

BCBSLA Authorizations ApplicationProfessional User Guide

18NW2309 05/16 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and incorporated as Louisiana Health Service & Indemnity Company.

CPT® only copyright 2016 American Medical Association. All rights reserved.

BCBSLA Authorizations Application Professional User Guide May 2016 Page 1 of 114

Using the BCBSLA Authorizations Application

The BCBSLA Authorizations application is designed to be an effective and easy-to-use tool for you and your organization. This application allows network providers to submit authorizations and provide clinical information 24 hours a day, seven days a week (except during maintenance times). Blue Cross and Blue Shield of Louisiana reviews and makes determinations during our standard operational hours of 8 a.m. - 4:30 p.m., Monday-Friday.

As an authorized user of the BCBSLA Authorizations application, it is important that you understand our expectations and your responsibilities. The BCBSLA Authorizations application is an asset of Blue Cross and Blue Shield of Louisiana. Any misuse, personal use or use for any business other than which you are authorized to perform is strictly prohibited and may be subject to criminal prosecution under federal and state laws. You must at all times, respect the confidentiality of all member (patient) information, and all data you are working with or may have access to through the BCBSLA Authorizations application. In addition, you are obligated to protect these assets by maintaining complete secrecy of your Login ID and Password. Under no condition can you reveal to anyone or allow anyone else to access the BCBSLA Authorizations application under your Login ID.

If you believe your password has been compromised, it is imperative that you reset your password. You are also expected to report any fraud, suspected fraud, abuse, privacy or confidentiality concerns to your employer (Hospital or Clinic management) and also directly to Blue Cross and Blue Shield of Louisiana. Please know that we monitor the system and any case where abuse is detected will be reported to your management and may result in either the loss of access for your Logon ID or legal action.

To report a security breach or if you have questions about accessing the BCBSLA Authorizations application, please contact the LinkLine at 1-800-216-BLUE (800-216-2583) or send an email to [email protected]



Table of Contents

Attestation Page .............................................................................................................................. 5

Dashboard ........................................................................................................................................ 7

Upper Right Hand Menu .............................................................................................................. 7

Dashboard Functions ................................................................................................................... 8

My Tasks List .................................................................................................................................. 14

BCBSLA Authorizations Application Troubleshooting .................................................................... 16

Submitting an Inpatient (IP) Admission Request ........................................................................... 17

Next Steps After Successfully Creating an Episode .................................................................... 22

View Initial Decisions Through Alerts: ....................................................................................... 35

Submitting an Inpatient (IP) Pre-Cert Request .............................................................................. 37


View Initial Decision Through Alerts: ......................................................................................... 60

Submitting an Outpatient (OP) Pre-Cert Request .......................................................................... 63



Submitting an Outpatient (OP) Extension Request ....................................................................... 86


Left Hand Navigation (LHN) Post Request Submission .................................................................. 95

Provider Supervisor Dashboard: .................................................................................................. 106

The New InterQual® Review Tools ............................................................................................... 109

CareEnhance® Review Manager Icons ..................................................................................... 109

Help Menu ............................................................................................................................... 110



Attestation Page

Prior to entering the BCBSLA Authorizations application, the user will be brought to the Attestation Page. Users must select the “Yes” button to enter the BCBSLA Authorizations application.

If the “No” button is selected, the user will not be permitted to enter the BCBSLA Authorizations application and must instead request authorizations by phone directly to our Authorizations Department at 1-800-523-6435.



Dashboard

Upper Right Hand Menu

The Upper Right Hand menu has the following: Help, Legends, Dashboard, Memory List, and User Actions.

1. Help: Clicking the Help icon opens a help window applicable to the screen the user is

currently on .

2. Legends: Clicking the Legends icon opens a window with a legend explaining icons

in the BCBSLA Authorizations application .

3. Dashboard: Clicking the Dashboard icon will bring the user back to their dashboard

.

4. Memory List: The Memory List allows the user to have more than one episode open at one time.

In the upper right hand screen, click on the Memory List icon

Click on the link to go to the episode you wish to work

Click Dashboard to return to the dashboard

Click the icon next to the episode you wish to exit Note: The memory list is limited to 5 episodes open at one time. A good practice is to close episodes as you complete them.


5. User Actions: Allows the following functions

My Profile: Shows what roles the user has been assigned and other demographic information.

App Shortcuts: Contains several keyboard shortcuts.

Logout: Allows the user to log out of the BCBSLA Authorizations application.

Dashboard Functions

1. My Calendar: Displays Activities on the calendar views. User may view the calendar in the following views:

Day Week Month Overdue: The Overdue tab shows a list of Activities that were due within the last

seven days. To view overdue Activities greater than seven (7) days old, click the filter button. Add a From Date and To Date and click search.


To refresh Activities on the dashboard, click the refresh button.

2. My Members: Enables the user to view a list of patients where the user is an attached provider in an authorization. This is a view only screen.

3. New Request: Enables the user to initiate authorizations through a Member Search

screen. On the Member Search screen the user must provide all information requested in the RED mandatory fields and either Subscriber ID or SSN.


The Mandatory Fields are as follows:

Member Last Name – enter at least two characters. Member DOB – use the MM/DD/YYYY format Subscriber ID or SSN

Note: If you do not enter Subscriber ID or SSN you will receive the below Message from webpage.

4. Search Request: Enables the user to view the status and progress of the request submitted for authorization. The Search Request screen enables the user to search for individual episodes or a list of episodes that the provider is attached to by using a variety of parameters. In addition, the user can filter their results by utilizing the Sort By/Order By function. Search results can display episodes submitted by multiple users.

Request Status: o Pending for Submission – the episode is in a “New” status and has been

created but has not been submitted

o InProcess – the episode is in an “Open or Open Request” status and has been submitted


o Processed – the episode is in a “Closed” status and has been submitted

View Cases: o PCP cases – has no functionality at the present time

o Non PCP cases – is a list of all episodes where the provider is attached to the episode

o MSO cases – has no functionality at the present time

o Clinics cases – is a list of all episodes where the provider is attached to the episode

o ACO Keyword – members who have been attributed to an ACO (affordable care organization) entity


Submitted By: Enables the user to search for requests submitted by a particular user under the same provider.

Cert Number: Enables the user to search for requests utilizing a certification number.


IP Next Review Date: User can search by date to determine when clinical documentation is due for a submitted inpatient episode.

OP Initial Due Date: User can search by date to determine when initial clinical documentation is due for a submitted outpatient episode.

5. My Inbox: This link has no user functionality at this time.

6. My Alerts: Displays a list of determination alerts sent by Blue Cross and Blue Shield of Louisiana to the application user. System generated decisions do not send alerts. If an initial automated decision on a submitted request is pending, we will review the request and an approved alert is sent to the users of the servicing facility and servicing physician attached to the request. The user can view alerts in this tab without refreshing the dashboard. The submitting provider will receive notification by phone if the decision is denied and the denial letter will be sent to the submitting provider In addition, the letter will be available for viewing in the Correspondence tab in the Left Hand Navigation.

7. Survey: This tab has no user functionality at this time.


My Tasks List

1. Alerts: Displays a list of determination alerts sent by Blue Cross and Blue Shield of Louisiana to the application user. System generated decisions do not send alerts. If an initial automated decision on a submitted request is pending, we will review the request and an approved alert is sent to the users of the servicing facility and servicing physician attached to the request. We will contact the submitting provider by phone if the decision is denied. A denial letter will also be sent to the submitting provider. In addition, the letter will be available for viewing under the Correspondence tab in the left hand navigation of the BCBSLA Authorizations application.

The count shown indicates the number of “Alerts” received. When an alert is deleted, the count will change upon refresh. While the alert will no longer display on the user’s dashboard, this does not affect it from displaying on other user dashboards.

The user will need to refresh the “My Tasks” using the refresh icon to have the most updated list of alerts.

To view an alert, click on “Alerts” in the left hand navigation

Click on the Episode Type or the Alert Message link to open the Episode associated with the alert.

To delete an Alert:

o Click on the Trash Can icon to delete a single alert.

o Select the box to the left of the member name and then click on the Clear button. This allows the user to delete single or multiple alerts at one time.


o To delete all alerts on the screen, click the All hyperlink next to Select

then click the Clear button:

Note: Alerts are sent to every user listed under a provider. When an alert is deleted by a user it only deletes the alert from that user’s dashboard; therefore, each individual user will need to delete alerts off of their own dashboard. Once an alert is deleted by a user, it can no longer be retrieved in that user’s dashboard.

2. Messages: No user functionality at this time.

3. Activities: Displays any Activities sent to the logged in user.

The count indicates the number of open Activities sent to the logged in user. Clicking “Activities” will open the user’s dashboard calendar.

o Activities assigned to the user will display.

o Patient name will be displayed on your dashboard. If the name is clicked, it will display the Activity name, Activity type, and notes.

o Click on “Open” to enter the episode.


4. Gaps In Care: No user functionality at this time

5. Actions Required: Displays a list of episodes that are in “New” status and have been created by the logged in user. These episodes have not been submitted and can be revised, completed and submitted. To open the episode, click on the Episode type.

6. Processed Requests: Displays a list of episodes that are in “Closed” status and have been created by the logged in user. To open the episode, click on the Episode type.

7. Outstanding Requests: Displays a list of episodes that are in “Open” or “Open Request” status and created by the logged in user. To open the episode, click on the episode type.

BCBSLA Authorizations Application Troubleshooting

For non-clinical concerns related to technical issues with the BCBSLA Authorizations application, users may contact our LinkLine, Monday-Friday, 8 a.m. to 5 p.m. at 1-800-216-BLUE (800-216-2583).


Submitting an Inpatient (IP) Admission Request

Note: Check patient’s eligibility in iLinkBLUE prior to initiating authorization in the BCBSLA Authorizations application.

1. From the Dashboard, click the New Request link, the Member Search screen will display.

2. Enter the patient’s information in the following mandatory fields:

Member Last Name: Enter at least two characters.

Member DOB: MM/DD/YYYY

Subscriber ID or SSN



3. Once mandatory fields are populated, click the Search button, and the Member Search Results screen will display.

4. To create the episode, select the Add Request icon in the Action column to the right of the patient’s Subscriber ID. The Add New Request screen will display along with the patient’s demographics.

5. For Episode Type select Inpatient from the dropdown.

An Inpatient Episode Type is defined as: Any Inpatient hospital acute care admission.


6. On the Add New Request screen enter the Episode Class, Urgency, Reason for Request, Member Class, Diagnosis, and Requestor’s Phone/Fax information. Once information is entered, click the Save button. Clarification of each field is as follows:

Episode Class: select Admission. An Admission is any unscheduled inpatient hospitalization including a direct admission.

Urgency: Select Standard. All Inpatient admissions are considered standard. Time request field populates 72 hours.

Time Request: This field auto-populates based upon the Episode Class and Urgency selected.


Reason for Request: Select the reason for requesting the authorization.

o Urgent- Select for direct admission.

Member Class: Select Medical.

Diagnosis:

o Enter the patient’s diagnosis code in the field provided. If the diagnosis code is unknown, type the description of the diagnosis or click The Search for

diagnosis icon to search for the code and the Diagnosis Code Search Form will open.


o Enter diagnosis description in the Description field.

o Click the Search button and results of the search will provide diagnosis codes with the description entered in the Diagnosis Code Search Results section.

o To select the Diagnosis Code click Select the diagnosis icon in the Action column to the right of the diagnosis, the diagnosis code and description will populate the Diagnosis field in the Add New Request screen.

Requestor’s Phone/Fax:

o Enter the Name, Phone, and Fax number of the person entering the information for the request.


Save: Click the Save button to create the episode. The Episode ID will display in the upper right hand corner next to the Delete Request button. This indicates an episode has been created successfully.

Note: Upon initial creation of an episode, it is in New status and has not been submitted. Once submitted, the episode status changes to Open Request.

Delete Request: If an error occurs during the creation of an episode, the episode can be deleted by using the Delete Request button. Example: Creating a request on the wrong patient, incorrect episode type, etc.

Next Steps After Successfully Creating an Episode

When an episode has been successfully created, the left hand navigation will populate seven steps.

STEP 1: Edit Request This step allows the user to edit the Add New Request Screen after an Inpatient

Episode has been created.

The Episode Type field can no longer be edited. All other fields may be updated. To save changes made in this step, the Save button must be selected.

STEP 2: Add Providers One Servicing Physician and one Servicing Facility must be added to the inpatient

episode when a request is submitted through the BCBSLA Authorizations application. The request cannot be submitted without these two roles attached.


The logged in user’s provider name will default as the Servicing Facility when the

episode is added. In the provider role column, click on the modify icon. Choose Servicing Physician as the provider role. Click the save button to save the changes. Servicing Physician will now display in the provider role.

Add a Servicing Facility to the inpatient request:

o Begin by clicking the Attach New button, the Attach Provider screen will display.

o Search for the provider by entering one or more of the search criteria and clicking the Search button.

o Once you have found the correct facility, choose Servicing Facility under the Provider Role Column.

Note: Do not select any other Provider Role (PCP, Requesting Provider, or Treating).

o Click the Attach icon under the Actions column to attach a provider to the episode.


o Once attached, the provider will appear on the Providers screen.

If the user is unable to locate a provider, use the following steps:

o Enter the Facility name in the Provider’s Last Name field.

o Change the Network Status dropdown from In Network to All Providers.

o Click the Search button to perform the search.

Note: If the user is still unable to locate the provider, contact our Authorization Department at 1-800-523-6435 to complete the authorization.


When a provider has been added in error, use the following steps to deactivate the provider:

o Select the Deactivate icon in the Actions column to the right of the provider you wish to deactivate.

o A message window will open, confirming you want to deactivate the provider. Click OK in the window.

o The deactivated provider will longer display.


STEP 3: UM Services In the Stay Request section of the UM Services screen, click the Add Stay button and

the Add Stay Request screen will display.

Select Medical Care for Service Type.

Select: Inpatient Hospital for Place of Service.

Enter the patient’s Actual Admit Date, this date reflects the date the patient presents to the facility.

Enter a numeric value in the LOS Requested# field, this number reflects the number of days being requested for inpatient stay.


Select Acute in the Requested Level of Care field.

Select the New InterQual Review icon to enter InterQual criteria. Refer to InterQual tab for details.

After saving your review in InterQual click OK in message box.

Next click the in the upper right hand corner of the InterQual screen to return to the Add Stay Request screen.

Click the Save button on the Add Stay Request screen to save information entered.

Note: InterQual must be performed prior to submitting the request for the possibility of an Automatic Approval.

If the user does not click the “Save” button on the Add Stay Request screen, the entered information will not be saved including any information entered in InterQual.


STEP 4: Add Documents

Supporting clinical documentation can be added by uploading a document. This is an optional step.

Click Add Documents on the left hand navigation, the Documents screen will display.

Click the Add Document button, the Upload Document window will open.

Enter Document Title: Web

Select Document Type: Provider Submitted Clinicals, from the dropdown menu.

Document Description field is an optional field; it can be used to describe the uploaded document.

To upload the document, click the Browse button located to the right of the Select Document field.

The Choose File to Upload window will open, select the name of the file and click the Open button.

The document name will now display in the Select Document field.

Click the Upload Document button to attach the document to the request, the document will now display on the Documents screen.


When the document has been uploaded successfully, a confirmation message displays on the Document screen.

Note: Once a document is uploaded, the user will not be able to view the document. Contact our Authorization Department if you have uploaded a document in error.

STEP 5: Add Diagnosis

This step is utilized when there are additional diagnoses to be entered. This is an optional step.

Click Add Diagnosis link in the left hand navigation, the Diagnosis screen will display.

Click the Add New Diagnosis button, the Add Diagnosis History screen will display.

Enter the date you are adding the diagnosis in the Start Date field.

Enter the diagnosis code in the Diagnosis Code field provided.

o When the diagnosis code is unknown, click the Search for diagnosis codeicon to the right of the Description field and the Diagnosis Code Search Form will open.


o Enter the diagnosis description in the Description field.

o Click the Search button and results will provide diagnosis codes with the description entered in the Diagnosis Code Search Results section.

o To select the Diagnosis Code click the Select the diagnosis icon in the Action column to the right of the diagnosis, the fields will auto populate on the Add Diagnosis History screen.

o To add multiple diagnoses, click the Add new diagnosis icon.


o When all diagnoses have been entered click the button, the diagnoses will now display on the Diagnosis screen.

STEP 6: Add Notes

This is an optional step.

Note: When submitting an initial authorization request, clinical information cannot be submitted through an Activity. It will only be accepted through InterQual Criteria, InterQual Note, Episode Note or Uploaded Documents.

To Add a Note:

o Click the Add Notes link in the left hand navigation and the Episode Notes screen will display.

o Click the Add Notes button and the Episode Notes screen will expand.

o The Date and Time will default to today’s date and time.

o Check the Sensitive Note box when documenting notes that reference a member’s mental health diagnoses, substance abuse, HIV/AIDS status or genetic testing information.

o Note Type: Defaults to Web.

o Type information in the Notes field provided.


o Click the Save button to add the note entered and the note will appear on the Episode Notes screen.

Notes: When you check the box next to “Sensitive Note” you will see a sensitive

note icon next to the name of the user who created the sensitive note.

A saved note cannot be deleted or modified.

When an addendum to the note entered must be made, click the add

addendum icon to add the addendum to the note previously added.

When documenting Sensitive Note information in an addendum the user must check the “Sensitive Note” box on the Episode Note screen to make the addendum sensitive.


STEP 7: Submit Request Viewing Abstract

o Prior to submitting a request, the user is given the option to View Abstract. This will enable the user to view a summary of all information entered in the request. To view the abstract click on the View Abstract button.

o A Print option is also available by clicking the Print icon located in the upper right hand corner of the View Abstract screen.

Submit Request

o To submit the request, select the Submit Request button. Message from webpage “Do you want to Submit this Request” displays. Click OK.

o Once OK is selected, the request is submitted and the information entered is no longer able to be modified. The request is securely sent to Blue Cross and Blue Shield of Louisiana.


o If a decision is approved, the below message will display.

A Confirmation Page will display and include the following:

Member’s Name- Patient’s name in submitted request.

Expected Decision Date- The date the provider is expected to submit clinical if clinicals were not submitted with the initial request.

Cert Number- Will display if an approved decision has been rendered. When the decision is pending, it will be blank.

Authorization Type- Refers to the episode type Inpatient. It is a hyperlink that returns the user to the episode and allows the user to add additional diagnoses, documents, Activity, or notes with an Activity.

UM Service Screen - Allows the user to view decisions made on an authorization. Automated decisions will display in the Stay Request section of the confirmation page.

o The decision will display under the Decision column.

o The Decision will be Approved or Pending.

o If the Decision is Approved:

The LOS assigned # will give the amount of days authorized.

Auth End Date will reflect when concurrent clinical information is due.

o If the Decision is Pending:

The user can hover over the bell icon in the Stay ID column to view further details.

We will review and make a determination.


View Initial Decisions Through Alerts:

When an approved determination is made, the users associated with the servicing physician will receive an alert on their dashboard.

To view the decision, click the My Alerts button on the Provider Links or Alerts in Left Hand Navigation.

An Alert message will inform the user of an Approved decision.

Click the Episode Type or the Alert Message; this will open the episode to the View Member Details Screen.


Click on UM Services in the Left Hand Navigation and the Stay Request screen will display.


o If the decision is Approved:


Auth end date will reflect when concurrent clinical information is due.

o If the decision is Denied, the submitting provider will receive a denial letter as well as notification by phone. In Addition, the letter will be available for viewing in the Correspondence tab in the Left Hand Navigation.


Submitting an Inpatient (IP) Pre-Cert Request

Note: Check patient eligibility in iLinkBLUE prior to initiating authorization in the BCBSLA Authorizations application. Requests for Pre-Cert Services should be initiated within three (3) months of the initial date of service.

1. From the Dashboard, click the New Request link, the Member Search screen will display.

2. The Mandatory Fields are as follows:

Member Last Name: Enter at least two characters.





3. Once the mandatory fields are populated click the Search button, Member Search Results screen will display.


5. For Episode Type select Inpatient from the dropdown.

An Inpatient Episode Type is defined as: Any pre-scheduled hospital acute care admission or a pre-scheduled inpatient procedure.



Episode Class: For Episode Class select pre-cert. Pre-cert is any Inpatient pre-scheduled admission including skilled nursing facility (SNF), rehabilitation facility, or long term care acute care facility (LTAC).

Urgency:

For Urgency select Standard or Expedited based on the following criteria:

o Standard- Any Inpatient procedure scheduled to be performed greater than 48 hours from the date of request or admission to a lower level of care. Time request field populates 5 Calendar days.

o Expedited- Any Inpatient procedure scheduled to be performed within 48 hours from the date of request or admission to a lower level of care. Time request field populates 24 hours.


Time Request: This field auto-populates based upon the Episode Class and Urgency (Standard or Expedited) selected.

Reason for Request: Select the reason for requesting the authorization.

o Other- Select for elective inpatient procedures.

o Clinical Trial – Select if the pre-cert service is for a Clinical Trial.

o Admit From Home – Select if the member is being admitted from home to SNF, Rehab or LTAC.

Note: Do not select Emergent, Urgent, or Divert as a reason for request when submitting a pre-cert request through the BCBSLA Authorizations application.

Member Class: Select a Member Class from the list below: Choose the most appropriate Member Class for service requested.

o Long Term Acute

o Medical

o Rehabilitative


o Skilled Care Unit

o Surgical

Diagnosis:

o Enter the patient’s diagnosis code in the field provided. If the diagnosis code is unknown, type the description of the diagnosis or click the Search for

diagnosis code icon to search for the code. The Diagnosis Code Search Form will open.




o To select the Diagnosis Code click the Select the diagnosis icon in the Action column to the right of the diagnosis, the diagnosis code and description will populate the Diagnosis field in the Add New Request screen.

Requestor’s Phone/Fax:

Enter the Name, Phone, and Fax number of the person entering the information for the request.



Delete Request: If an error occurs during the creation of an episode, the episode can be deleted by using the Delete Request button. Example: Creating a request on the wrong patient, incorrect episode type, etc.




STEP 1: Edit Request

This step allows the user to edit the Add New Request Screen after an Inpatient Episode has been created.


STEP 2: Add Providers

One Servicing Physician and one Servicing Facility must be added to the inpatient episode when request is submitted through the BCBSLA Authorizations application. The request cannot be submitted without these two roles attached.


episode is added. In the provider role column, click on the modify icon. Choose Servicing Physician as the provider role. Click the save button to save the changes. Servicing physician will now display in the provider role.


Add Servicing Facility to the inpatient request as follows:

o Begin by clicking the Attach New button, the Attach Provider screen will open.

o Search for the facility by entering one or more of the search criteria and clicking the Search button.

o Once you have found the correct facility, choose Servicing Facility under the Provider Role Column.

Note: Do not select any other Provider Role (PCP, Requesting Provider, or Treating)





o Enter the facility name in the Provider Last Name field.



Note: If unable to locate the provider, contact our Authorization Department at 1-800-523-6435 to complete the authorization.





o The deactivated provider will no longer display.

STEP 3: UM Services

In the Stay Request section of the UM Services screen, click the Add Stay button, the Add Stay Request screen will display.

Select a Service Type from the list below:

o Hospice – Select for inpatient hospice only. Requires a Stay Request and a Service Request.

o Chemotherapy – Requires a Stay Request and a Service Request.


o Surgical – Requires a Stay Request and a Service Request. When requesting a preoperative inpatient day, do not submit a request through the BCBSLA Authorizations application. Instead, contact our Authorization Department for authorization by phone at 1-800-523-6435 or via fax at 1-800-586-2299.

o Medical – Requires a Stay Request and/or a Service Request. Select when none of the other options are applicable.

o Long Term Acute Care (LTAC) services require a Stay Request ONLY.

o Rehabilitation – Requires a Stay Request ONLY.

o Skilled Nursing Facility – Requires a Stay Request ONLY.

Note: For all transplants (including evaluations and listings), you must contacting our Authorization Department by phone at 1-800-523-6435 or via fax at 1-800-586-2299.

Select the Place of Service from the list below:

o Inpatient Hospital- includes Long Term Acute Care (LTAC)

o IP Rehab Facility

o Skilled Nursing Facility


o Enter the patient’s Actual Admit Date; this date reflects the date the patient is scheduled to be admitted to the facility. Once submitted, if the admit date changes, contact our Authorization Department by phone at 1-800-523-6435 or via fax at 1-800-586-2299.

o Enter a numeric value in the LOS Requested# field, this number reflects the number of days being requested for inpatient stay.

o Select the Requested Level Of Care from the list below:

Acute Hospice Inpatient Rehab LTAC Acute LTAC ICU LTAC Subacute Skilled Nursing

Note: Admissions to a lower level of care (SNF, Rehab, LTAC) must be reviewed and are not eligible for Automatic Approval.

If the pre-cert only contains a Stay Request then access IQ on the Stay Request Screen.

If the pre-cert contains a Stay and Service Request, then access IQ on the Service Request Screen.


o Click the Save button to return to the Stay Request/Service Request screen.

Note: If the user does not click the Save button on the Add Stay Request screen, the entered information will not be saved including the InterQual Review.

o If applicable, click the Add Service Request button and the Add Service Request screen will display.

o Enter a Service Type from the list below:

Hospice

Chemotherapy

Surgical

Medical (if applicable)


Select the Place Of Service from the list below:

o Inpatient Hospital

o Hospice IP

o Enter the appropriate Service Code in the field provided. If the service code is

unknown, type the description of the service in the service code field or click

on the Search for service code icon to search for the code. The Service Code Search screen will display.

o Click on the dropdown and select the appropriate Type of Code: CPT® or HCPCS.

o Enter service code description in the Description field provided.


o Click the Search Codes button and results of the search will provide codes with the description entered in the Service Code Search Results section.

o To select the Service Code click the Select the CPT® code icon in the Action column to the right of the description, the service code and description will populate the Service Code field on the Add Service Request screen.

o Enter Requested# in the field provided. This indicates the amount of a particular service the user is requesting.

o Enter the Start Date and End Date in the fields provided or by selecting the

calendar icon.

o Select the New InterQual Review icon to enter InterQual criteria. Refer to InterQual tab for details.

o After saving your review in InterQual, click OK in the message box.


o Next click the in the upper right hand corner of the InterQual screen to return to the Add Service Request screen in the BCBSLA Authorizations application.

Note: InterQual must be performed prior to submitting the request for the possibility of an Automatic Approval.

o Enter a Service Request for every code that is being requested.

o If the pre-cert contains a Service Request then access IQ in the Service Request screen.

o If multiple codes are entered in Service Request, perform the InterQual review on the primary CPT®/HCPCS code.

If the user does not click the Save button on the Add Service Request screen, the entered information will not be saved including the InterQual Review.





Enter Document Title: Web

Select Document Type: Provider Submitted Clinicals from the dropdown menu.


To upload the document, click the Browse button located on the right of the Select Document field.


The Choose File to Upload window will open, select name of the file and click the Open button.

The document name will now display in the Select Document field.

Click Upload Document button to attach the document to the request, the document will now display on the Documents screen.

When the document has been uploaded successfully, a confirmation message displays on the Document screen.





Click the Add Diagnosis link on the left hand navigation, the Diagnosis screen will display.



Enter the diagnosis code in the Diagnosis Code field provided.

o When the diagnosis code is unknown, click the Search for diagnosis code icon to the right of the Description field and the Diagnosis Code Search Form will open.








STEP 6: Add Notes


Note: When submitting an initial authorization request, clinical information cannot be submitted through an Activity. It will only be accepted through InterQual Criteria, InterQual Note, Episode Note or Uploaded Documents. Additional primary physicians with a procedure should be added in this section. In circumstances when multiple surgeons are utilized for a procedure, additional Servicing Physicians should be added in the notes section.

To Add a Note:


o Click the Add Notes button and the Episode Notes screen will expand.






o Click the Save button to add the note entered and the note will now appear on the Episode Notes screen.

Notes:

When you check the box next to Sensitive Note you will see a Sensitive note

icon next to the name of the user who created the sensitive note. A saved note cannot be deleted or modified. When an addendum to the note entered must be made, click the Add

addendum icon to add the Addendum to the note previously added.

When documenting Sensitive Note information in an addendum, the user must check the Sensitive Note box on the Episode Note screen to make the addendum sensitive.

STEP 7: Submit Request

Viewing Abstract

o Prior to submitting a request, the user is given the option to View Abstract. This will enable the user to view a summary of all information entered in the request. To view the abstract, click on the View Abstract button.



Submit Request

o To submit the request, select the Submit Request button. A message from webpage “Do you want to Submit this Request” displays. Click OK.

o Once the OK button is selected, the request is submitted and the information entered is no longer able to be modified. The request is securely sent to Blue Cross and Blue Shield of Louisiana.

o A Confirmation Page will display and include the following:

Member’s Name- Patient’s name in submitted request.

Expected Decision Date- The date the provider is expected to submit clinical if they were not submitted with the initial request.

Cert Number- Will display if an approved decision has been rendered. When the decision is pending it will be blank.

Authorization Type- Refers to the episode type Inpatient. It is a hyperlink that returns the user to the episode and allows the user to add additional diagnoses, documents, Activity, or notes with an Activity.


UM Service Screen - Allows the user to view decisions made on an authorization. Automated decisions will display in the Stay/Service Request section of the confirmation page.


o The Decision will be Approved or Pending. If a service request exists, the stay and service decisions will match.

o If the Stay Request Decision is Approved:

The LOS assigned # in the Stay Request will give the amount of days authorized.

Auth End Date in the Stay Request is when concurrent clinical information is due.

o If the Stay/Service Request Decision is Pending:

The user can hover over the bell icon in the Stay/Service ID column to view further details.


o If a decision is Approved, the below message will display:


View Initial Decision Through Alerts:

When an approved determination is made, the users associated with the servicing physician will receive an alert on their dashboard.





Select UM Services in the left hand navigation, the Stay/Service Request screen will display.

o For a stay request, if the decision is Approved:


Auth end date is when concurrent clinical information is due.

o For a stay request, if the decision is Denied:

The admission is denied and the submitting provider will receive a denial letter as well as phone notification. In addition, the letter will be available for viewing in the correspondence tab in the Left Hand Navigation.

o For a Stay and Service request, If the decision is Approved in both the Stay and Service Request:

The admission and service are approved.

The LOS assigned #, in the Stay Request, will give the amount of days authorized.

Auth End Date, in the Stay Request, is when concurrent clinical information is due.

Assigned# will have the number of services/units/visits approved for that service code.


o For Stay and Service request, if the decision is Denied in both the Stay and Service Request:

The service and admission are denied. The submitting provider will receive a denial letter as well as phone notification. In addition, the letter will be available for viewing in the correspondence tab in the Left Hand Navigation.

o If the Stay Request Decision is Approved and there is a combination of Approved and Denied Service Request decisions, the user will receive notification of the Denied Service by phone and the denial letter will be sent to the submitting provider. In addition, the letter will be available for viewing in the Correspondence tab in the Left Hand Navigation.


Submitting an Outpatient (OP) Pre-Cert Request

Note: Check patient’s eligibility in iLinkBLUE prior to initiating authorization in the BCBSLA Authorizations application. Request for Pre-Cert Services should be initiated within 3 months of initial date of service.

1. From the Dashboard, click the New Request link and the Member Search screen will display.

2. Enter the patient’s information in the following mandatory fields: Member Last Name: Enter at least two characters.





3. Once mandatory fields are populated, click the Search button and Member Search Results screen will display.


5. For Episode Type select Outpatient from the dropdown.

An Outpatient Episode includes an outpatient procedure (other examples include Home Health, Durable Medical Equipment, Outpatient Hospice, Dialysis, Day Surgery, etc.).



Episode Class – For Episode Class select pre-cert. Pre-cert includes any outpatient pre-scheduled service.

Urgency – For Urgency select Standard or Expedited based on the criteria below:

o Standard- Any Outpatient service scheduled to be performed greater than 48 hours from the date of request. Time request field populates 5 Calendar days.

o Expedited- Any Outpatient service scheduled to be performed within 48 hours from the date of request. Time request field populates 24 hours.

Time Request - This field auto-populates based upon Episode Class and Urgency (Standard or Expedited) selected.


Reason for Request – Select the reason for requesting authorization.

o Other – Select for elective or outpatient procedure.

o Clinical Trial – Select if the Pre-cert Service is for a Clinical Trial.

Note: Do not select Emergent, Urgent, Divert or Admit From Home as a reason for request when submitting an outpatient pre-cert request.

Member Class

o Choose Outpatient

Diagnosis

o Enter the patient’s diagnosis code in the field provided. If the diagnosis code is unknown, type the description of the diagnosis or click the Search for diagnosis

code icon to search for the code, the Diagnosis Code Search Form will open.


o Enter the diagnosis description in the Description field provided.

o Click the Search button and the results of the search will provide diagnoses with the description entered in the Diagnosis Code Search Results section.

o To select the Diagnosis Code click the Select the diagnosis icon in the Action column to the right of the diagnosis, the diagnosis code and description will populate the Diagnosis field on the Add New Request screen.

Requestor’s Phone/Fax

o Enter the Name, Phone, and Fax number of the person entering the information for the request.




Delete Request: If an error occurs during the creation of an episode, the episode can be deleted by using the Delete Request button.

Example: Creating a request on the wrong patient, incorrect episode type, etc.




STEP 1: Edit Request

This step allows the user to edit the Add New Request Screen after an Outpatient Episode has been created.


STEP 2: Add Providers

One Servicing Physician and/or one Servicing Facility must be added to the outpatient episode when a request is submitted through the BCBSLA Authorizations application.


episode is added. In the provider role column, click on the modify icon. Choose Servicing Physician as the provider role. Click the save button to save the changes. Servicing Physician will now display in the provider role.

Add the Servicing Facility to the outpatient request as follows:

o Begin by clicking the Attach New button, the Attach Provider screen will open.


o Search for the provider by entering one or more of the search criteria and clicking the Search button.

o Once you have found the correct facility choose Servicing Facility under the Provider Role Column.

Note: Do not select any other Provider Role (PCP, Requesting Provider, or Treating.




o Enter the facility name in the Provider’s Last Name field.




Note: If the user is still unable to locate the provider, contact our Authorization Department at 1-800-523-6435 to complete the authorization.





o The deactivated provider will no longer display.

STEP 3: UM Services

In the Service Request section of the UM Services screen, click the Add Service button and the Add Service Request screen will display.

Note: All Outpatient episodes require a Service Line.

o Enter a Service Type from the list below:

Cardiac Rehabilitation

Diagnostic Lab

Diagnostic Service

Diagnostic X-ray

Dialysis

Durable Medical Equipment Purchase

Durable Medical Equipment Rental

Home Health Visits

Hospice

Infusion

Injection

Observation

Occupational Therapy

Physical Medicine (PT)

Private Duty Nursing

Pulmonary Rehabilitation

Radiation Therapy

Speech Therapy

Surgical

Sleep Study

Note: The service types listed above require a service request for each individual CPT®/HCPCS code entered.


o Select the Place of Service from the list below:

Ambulatory Surgical Center

ESRD Treatment Facility

Home

Independent Lab

Office

Outpatient Hospital

Outpatient Rehab Facility

o Enter the appropriate Service Code in the field provided. If the service code is unknown, type the description of the service in the service code field or click on

the Search for service code icon to search for the code. The Service Code Search screen will display.

o Click on the dropdown and select the appropriate Type of Code: CPT® or HCPCS.


o Enter service code description in the Description field provided.

o Click the Search Codes button and results of the search will provide codes with the description entered in the Service Code Search Results section.

o To select the Service Code click the Select the CPT® code icon in the Action column to the right of the description, the service code will populate the Service Code field on the Add Service Request screen.

Enter the Requested # in the field provided. This indicates the amount of a particular service the user is requesting.


Enter the Start Date and End Date in the fields provided or by selecting the calendar

icon. Providers can enter a date span of up to one month per service line.

Select the New InterQual Review icon to enter InterQual criteria. Refer to InterQual tab for details.

o After saving your review in InterQual click OK in message box.

o Next click the in the upper right hand corner of the InterQual screen to return to the Add Service Request screen in BCBSLA Authorizations application.

Note: InterQual must be performed prior to submitting the request for the possibility of an Automatic Approval. If multiple codes are entered perform InterQual review only on the primary CPT®/HCPCS code under the service request line.


After exiting the InterQual episode, click the Save button on the Add Service Request screen to save information entered.

Note: If the user does not click the Save button on the Add Service Request screen, the entered information will not be saved including the InterQual Review.





Enter Document Title: Web.

Select Document Type: Provider Submitted Clinicals from the dropdown menu.


To upload the document, click the Browse button located on the right of the Select Document field.


The Choose File to Upload window will open, select the name of the file you would like to upload and click the Open button.

o The document name will now appear in the Select Document field.

o Click the Upload Document button to attach the document to the request, the document will now display on the Documents screen.

o When the document has been scanned and uploaded successfully a confirmation message appears on the Document screen.




Click the Add Diagnosis link on the left hand navigation, the Diagnosis screen will display.



o Enter the date you are adding the diagnosis in the Start Date field.

o Enter the diagnosis code in the Diagnosis Code field provided.

o When the diagnosis code is unknown, click the Search for diagnosis code icon to the right of the Description field, the Diagnosis Code Search Form will open.







STEP 6: Add Notes:


Note: When submitting an initial authorization request, clinical information cannot be submitted through an Activity. It will only be accepted through InterQual Criteria, InterQual Note, Episode Note or Uploaded Documents. In circumstances when multiple surgeons are utilized for a procedure, additional servicing physicians should be added in the Notes section.

To Add a Note:



o Click the Add Notes button, the Episode Notes screen will expand.





o Click the Save button to add the note entered and the note will now appear on the Episode Notes screen.

Notes: When you check the box next to Sensitive Note you will see a Sensitive note

icon next to the name of the user who created the sensitive note. A saved note cannot be deleted or modified. When an addendum to the note entered must be made, click the Add

addendum icon to add the Addendum to the note previously added.

When documenting Sensitive Note information in an addendum the user must check the Sensitive Note box on the Episode Note screen to make the addendum sensitive.


STEP 7: Submit Request

Viewing Abstract

o Prior to submitting a request, the user is given the option to View Abstract. This will enable the user to view a summary all information entered in the request. To view the abstract click on the View Abstract button.


Submit Request

o To submit the request, select the Submit Request button. Message from webpage “Do you want to Submit this Request” displays. Click OK.

o Once the OK button is selected, the request is submitted and the information entered is no longer able to be modified. The request is securely sent to Blue Cross and Blue Shield Louisiana.


o A Confirmation Page will display and include the following:

Member’s Name- Patient’s name in the submitted request.

Expected Decision Date- The date the provider is expected to submit clinicals if clinicals were not submitted with the initial request.

Cert Number-Will display if an approved decision has been rendered. When the decision is pending it will be blank.

Authorization Type- Refers to the episode type Outpatient. The hyperlink returns the user to the episode and allows the user to add additional diagnoses, documents, Activity or notes with an Activity.

UM Service Screen - Allows the user to view decisions made on an authorization. Automated decisions will display in the Service Request section of the confirmation page.


o The Decision will be Approved or Pending.


The Assigned # column will show the amount of services/units/visits approved.

Auth Start Date and Auth End Date represents the dates in which the service requested must be performed. If the dates of service require modification after submission, please contact our Authorization Department at 1-800-523-6435 to update the dates of service.


o If the Decision is Pending:

The user can hover over the bell icon in the Service ID column to view further details.


o If a decision is Approved, the below message will display.



When an approved determination is made, the users associated with the Servicing Physician will receive an alert on their dashboard.



o Click the Episode Type or the Alert Message; this will open the episode to the View Member Details Screen.

o Select UM Services in the left hand navigation, the Service Request screen will display.




The Assigned # will give the amount of services/units/visits authorized.

Auth Start Date and Auth End Date represents the dates in which the service requested must be performed. If the dates of service require modification after submission please contact our Authorization Department at 1-800-523-6435 to update the dates of service.

o If the Decision is Denied:

The provider will receive a denial letter as well as phone notification. In addition, the letter will be available for viewing in the Correspondence tab in the Left Hand Navigation.

o There is a possibility to receive a combination of Approved and Denied decisions if there are multiple Services requested. Each Service Request decision will either approve or deny that individual Service.


Submitting an Outpatient (OP) Extension Request

1. Click on Search Request link at the top of the screen. Then type in a search parameter using any field below and click the Search button.

2. Search results will display the appropriate OP episode. The Service Extension icon to extend the request will display under the Actions column.

3. To open the OP episode, click on the Service extension icon; or Click on the OP hyperlink in the Episode Type column.

4. The View Member Details screen will display.


5. Click on UM Services in Left Hand Navigation (LHN). This tab is mandatory to submit an extension request.

6. Click the Service Extension icon on the service line for the code that needs to be extended and the Extension Service Request screen will be displayed.

7. Enter the Requested # in the field provided. This indicates the amount of a particular service the user is requesting.

8. Enter the Start Date and End Date in the fields provided or by selecting the

Calendar icon. The extension Start Date cannot be earlier than the previous approved End Date. Providers can enter a date span of up to one month per service line.

9. Select the New InterQual Review icon to enter InterQual Criteria. Refer to the InterQual tab for details.


10. After saving your review in InterQual, click OK in the message box. Next click the icon in the upper right hand corner of the InterQual screen to return to Service Request screen in BCBSLA Authorizations application. Then, click the Save button on the Extension Service Request screen to save the information entered.

Notes: InterQual must be performed prior to submitting the extension request for the

possibility of an Automatic Approval. If multiple codes are being extended, then perform the InterQual Review only on the Primary CPT®/HCPCS code under the Service Request line.

After exiting the InterQual episode, click the Save button on the Add Service Extension Request screen to save information entered.

If the user does not click the Save button on the Add Extension Service Request screen, the entered information will not be saved including the InterQual Review.


11. The following steps in the Left Hand Navigation are optional for an Extension Request:

Diagnosis Details

Clinical Documents

Activities

Notes

12. Click Submit Extension button in the Left Hand Navigation: This is a mandatory step to submit an extension.


Prior to submitting an extension request, the user is given the option to View Abstract. This will enable the user to view a summary of all information entered in the extension request. To view the abstract click on the View Abstract button.

A print option is also available by clicking the Print icon located in the upper right hand corner of the view abstract screen.


13. Submit Extension

To submit the request, select the Submit Extension button. Message from webpage “Do you want to Submit the Request” displays. Click OK.

Once OK is selected, the extension request is submitted and the information entered is no longer able to be modified. The extension request is securely sent to Blue Cross and Blue Shield of Louisiana.

A Confirmation Page will display and include the following:

o Member’s Name- Patient’s name in submitted request.

o Expected Decision Date- The initial Expected Decision Date will display, this is not an applicable field for extensions.

o Cert Number- The certification number will display.

o Authorization Type- Refers to the episode type Outpatient, the hyperlink returns the user to the episode to add additional diagnoses, documents, Activity or notes with an Activity.

o UM Service Screen - Allows the user to view decisions made on an authorization. Automated decisions will display in the Service Request section of the confirmation page.

The decision will display under the Decision column.

The Decision will be Approved or Pending.

If the Decision is Approved:

o The Requested # will give the amount of services/units/visits authorized.

o Auth Start Date and Auth End Date represents the dates in which the service requested is authorized to be performed. If the dates of service require modification after submission, please contact our Authorization Department at 1-800-523-6435 to update the dates of service.


If the Decision is Pending:

o The user can hover over the bell icon in the Service ID column to view further details.

o We will review and make a determination.

If a decision is Approved, the below message will display.



When an approved determination is made, the users at the servicing facility will receive an alert on their dashboard.





Select UM Services in the left hand navigation, the Service Request screen will display.

The decision will display under the Decision column.

If the Decision is Approved:

o The Assigned # will give the amount of services/units/visits authorized.

o Auth Start Date and Auth End Date represents the dates in which the service requested is authorized to be performed. If the dates of service require modification after submission, please contact our Authorization Department at 1-800-523-6435 to update the dates of service.

If the Decision is Denied:

o The submitting provider will receive a denial letter as well as phone notification. In addition, the letter will be available for viewing in the Correspondence tab in the Left Hand Navigation.

There is a possibility to receive a combination of Approved and Denied decisions if there are multiple Service Extensions requested. Each Service Extension Request decision will either approve or deny that individual service.


Left Hand Navigation (LHN) Post Request Submission

The LHN allows the user to view information after submission of the request has been made. Once a request has been submitted to us through the BCBSLA Authorizations application, the provider will be able to access the request and view information by utilizing the links provided in the Left Hand Navigation.

1. View Member Details: Displays the member’s demographics information.

2. UM Services: Allows the user to view the Stay Request and/or Service Request submitted and whether the request for authorization is Pending, Approved or Denied.

The InterQual summary icon is available by selecting the downward arrow icon located in the Actions column in the Stay Request or Service Request sections.


3. Providers: Allows the user to view the previously attached Servicing Physician and Servicing Facility.

4. Diagnosis Details: Allows the user to add new diagnosis codes and view previously entered diagnosis codes submitted with the request.

To add a diagnosis: Click the Add New Diagnosis button, the Add Diagnosis History screen will display.


Enter the diagnosis code in the diagnosis field provided.


When the diagnosis code in unknown, click the Search for diagnosis code icon to the right of the Description field; the Diagnosis Code Search Form will open.

Enter diagnosis description in the Description field.

Click the Search button and results of the search will provide diagnosis codes with the description entered in the Diagnosis Code Search Results section.

To select the Diagnosis Code, click the check box Select the diagnosis icon in the Action column to the right of the diagnosis, the fields will auto populate on the Add Diagnosis History screen.


To add multiple diagnoses, click the Add new diagnosis icon. When all diagnoses

have been entered, click the button and the diagnoses will now display on the Diagnosis screen.

5. Clinical Documents: Allows the user to attach documents at any time.

To attach a new document:

o Click Add Documents on the left hand navigation, the Documents screen will display.

o Click the Add Document button, the Upload Document window will open.

o Enter Document Title: Web

o Select Document Type: Provider Submitted Clinicals.

o Document Description field is an optional field; it can be used to describe the document being uploaded.

o To upload the document, click the Browse button located to the right of the Select Document field.

o The Choose File to Upload window will open, select the name of the file and click the Open button.


o The document name should now display in the Select Document field.

o Click the Upload Document button to attach the document to the request, the document will now display on the Documents screen.

o When the document has been scanned and uploaded successfully, a confirmation message displays on the Document screen.



6. Correspondence: Allows the user to view and print Blue Cross and Blue Shield of Louisiana generated letters.

Note: Not all letters are available for viewing.

To view a letter, click on the notification name link.

Click the Open button on the File Download pop-up message.

To print a letter, use the print icon at the top of the letter.

7. Activities: Allows the user to communicate with Blue Cross and Blue Shield of Louisiana after submission of a request has been made.

Note: The BCBSLA Authorizations application allows providers to send communications to Blue Cross and Blue Shield of Louisiana through Activities, 24 hours a day/7 days a week with the exception of any maintenance times, however, we will respond to Activities during normal operational hours of 8 a.m. to 4:30 p.m.


Initiate Communication through an Activity as follows:

o Click Activities in the Left Hand Navigation, the Activities screen will display.

o Click Add New Activity button, the Add Activity screen will display.

Fill out the Add Activity screen as follows:

o Activities: Select Portal Communication.

o Activity Type: Select IP or OP based on the type of request submitted.

o Notes: Type in information, communication data should be concise.

o Activity Date: Select the date the Activity should be sent to Blue Cross and Blue Shield of Louisiana.

o Activity Status: Defaults to Open.

o Activity Priority:

Select Critical- When the Note field contains clinical information.

Select Medium- When the Note field contains non-clinical information.

Assign To: Select Provider Requests (Worklist).

Note: The Provider Requests worklist is the only acceptable recipient of communication through the BCBSLA Authorizations application.


Click the Save button to send the Activity.

The Activity will now appear on the Activities screen.

Responding to an Activity sent by Blue Cross and Blue Shield of Louisiana

o From the Dashboard, select the Activity received by clicking on the member’s name. View Activity details including note.

o Click Open, the Add Interaction Screen will display.


o Document on the Add Interaction Screen as follows:

Follow Up Required: Defaults to No.

Interaction Status: Select Successful.

Interaction Outcome: Select Portal Communication Complete.

Notes: Do not enter information in this field.

Click Save.


Click the Add New Activity button, the Add Activity screen will display.

Activities: Select Portal Communication.

Activity Type: Select IP or OP based on the type of request submitted.

Notes: Type in response, communication data should be concise.

Activity Date: Select the date the Activity should be sent.

Activity Status: Defaults to Open.

Activity Priority:

i. Select Critical – When the Note field contains clinical information.

ii. Select Medium – When the Note field contains non-clinical information.

Assign To: Select Provider Requests (Worklist).

Note: The Provider Requests worklist is the only acceptable recipient of communication through the BCBSLA Authorizations application.

Click Save to send the Activity.


To view closed Activities: Click the Show/hide icon to expand the Closed Activity section.

8. Alerts – No functionality at this time.

9. Messages – No functionality at this time.

10. Note – Allows the user to view episode related notes.

Note: If the user adds notes to the Notes tab and does not send an Activity, then we will not be aware of the additional information. Therefore, additional information entered in notes after initial submission/extension will not be accepted without a corresponding Activity.

11. Submit Extension – Allows the user to submit an extension. Refer to Submitting an Outpatient Extension sections for details.

Reminder: The BCBSLA Authorizations application allows providers to submit authorizations and upload documents to provide clinical information 24 hours a day/ 7 days a week with the exception of any maintenance times, however, we will review and make determinations during normal operational hours of 8 a.m. to 4:30 p.m.


Provider Supervisor Dashboard:

The Supervisor Dashboard enables a user to reassign Activities between users listed under a specified provider. Contact your Administrative Representative for information regarding access to this tool.

1. The Provider Supervisor tab will display at the top of the screen.

2. Click on the Provider Supervisor tab.

The Reassign Activities screen will display with the following fields:

o From Date-Enter the begin date of search. This field is optional.

o To Date-Enter the ends date of search. This field is optional.

o Select User-Select the user whose Activities will be reassigned. This is a mandatory field.

o Type -Will default to “Activities to be completed”. This is a mandatory field.

The user can also sort the results by the following fields:

o Sort By-Allows the user to sort by:

Activity Due Date Activity Name Activity Type


o Order By-Allows the user to display the Sort By in Descending or Ascending order.

o Click on the icon to add an additional sort by option.

o Click on the delete icon to delete a sort by option.

3. Click on the Search and Reassign button .

4. The Search Results screen will display the Activities that met the search parameter.

To select Individual or multiple Activities, click on the box in the Select column :

o Select a user to whom the Activity will be reassigned in the Reassign User Column.

o Click on the Reassign button.

o A webpage message will display and ask “Do you want to Reassign?”


o Click the OK button.

o The Reassign Activities screen will display and the Activities will now be reassigned. Follow-ups reassigned successfully banner will display.

To select all of the Activities that display in the Search Results:

o Click on the Reassign All button .

o The Select Nurse screen will display.

o In the Reassign Nurse box, click in the box next to the user to whom the Activities are to be reassigned.

o Click the Reassign button.

o The Reassign Activities screen will display and the Activities will now be reassigned to the selected user or evenly distributed to all users when multiple users in the Reassign Nurse box are selected. Follow-ups reassigned successfully banner will display.

Note: If the re-assigned user has their calendar blocked on the activity due date, the supervisor will get a message from webpage stating nurse is not available on specified date. Click OK and choose a different re-assigned user.


The New InterQual® Review Tools

CareEnhance® Review Manager Icons

New InterQual Review

Enables the user to add an InterQual review to an initial or an extension request from within the authorization portal.

o Click the New InterQual Review icon to launch Review Manager.

o The diagnosis/ CPT® code will default in the Medical Code field and will display applicable subsets.

o If the results do not display a desired subset, then delete the medical code and search by product.

o Click on appropriate subset link.

o On the lower left of the Review screen, click Next icon to go to the next review screen.

o View the subset note.

o Click Next on the Review screen.

o If applicable, select a review type.

o Depending on the product selected, the user will evaluate criteria for the selected subset in one of the following formats:

o Evaluate criteria in a decision tree. Then, click Record Outcome in the navigation pane; or

o Evaluate criteria in a medical review. Then click Next.

o Record review outcome. Then, click Next.

o View the review summary.

o To save the review, click Save.

Proprietary and Confidential – For BCBSLA Authorization Portal Training Only.

The software images and McKesson Clinical Content contained in this document are the copyright of McKesson Corporation and/or one if its subsidiaries. All rights reserved.


Existing InterQual Review

Enables the user to view an existing review(s).

InterQual Book View

Enables the user to view InterQual Criteria

Help Menu

1. CareEnhance Review Manager® Enterprise Software Help

The Review Manager Help is a centralized information resource for Review Manager. The user is able to utilize it as: Online Help while using Review Manager A general reference document A self-paced learning tool

Proprietary and Confidential – For BCBSLA Authorization Portal Training Only.



2. Guide to Conducting Reviews

This guide provides an overview of using CareEnhance Review Manager to conduct reviews with InterQual Criteria. The guide is organized as follows: Chapter 1: Using the Menu Bar

Chapter 2: Conducting Reviews

Chapter 3: Using Quality Indicator Checklist and Transition Plans

Chapter 4: Managing Authorization Requests

Chapter 5: Exporting Reviews

Chapter 6: Generating InterQual® CriteriaView™ Clinical Scenarios

Proprietary and Confidential — For BCBSLA Authorization Portal Training Only.



3. InterQual Clinical Reference

The InterQual Clinical Reference provides the user with information about InterQual Criteria and conducting reviews. Including product-specific review processes, clinical revisions, bibliographies, Abbreviations & Symbols and a Drug List

Clinical Reference 2015- The Clinical Reference provides important information about InterQual Criteria and how to conduct reviews. The user may use this Clinical Reference while conducting a review, or as a resource of medical information.

Abbreviations and Symbols- Provides the user with a list of abbreviations and symbols mentioned within the criteria and notes.

Drug List- A tool to assist users by categorizing drug names and classes mentioned within the criteria and notes.

o It is organized using a combined alphabetical listing of common generic and trade names with their associated chemical class (e.g., Beta-Blockers) and functional class (e.g., Antihypertensive).

o Multi-drug combinations are represented using slashes.




4. About CareEnhance Review Manager

Displays information about Review Manager, including version and build numbers, as well as important contact information.

5. Interqual Criteria:

For Direct Admission:

LOC: Acute Adult or LOC: Acute Pediatric

For Pre-cert Admission to a Lower Level of Care:

LOC: Long Term Acute Care LOC: Rehabilitation LOC: Subacute/SNF

For Home Health:

LOC: Home Care Q & A

For outpatient therapy:




LOC: Outpatient Rehabilitation and Chiropractic

For Pre-cert Procedure:

CP: Procedures and choose the appropriate category

For Durable Medical Equipment:

CP: Durable Medical Equipment

If your service code is related to a medical policy and InterQual Clinical Content is reviewed on the service line, the InterQual search screen will display applicable criteria sets for MPRM (Medical Policy Reference Manual).