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If there are multiple doctors performing a surgery, can you add a co-surgeon to the prior authorization? The Availity prior authorization workflow includes the requesting provider, rendering provider or provider providing the service and facility if applicable.

If the member becomes active as of May 1, for example, but the provider is trying to submit the authorization in April, are they able to submit the request online? When a provider enters a prior authorization request, an eligibility and benefits check appears.

If the member isn't loaded in our system as an active member, it will return a message that the member isn't eligible.

After a provider sets up an authorization and they want to send additional clinicals, can they come back and attach them after the authorization is submitted?

The provider will need to fax any additional documents to Premera. Please include the request's certification reference number on your fax. Will the tool show you or stop you if the prior authorization request has already been submitted, so that you don't duplicate the request? Is there a prior authorization form to fill out? No, the Availity prior authorization tool is an online workflow that walks the requester through the process step-by-step. The steps could be different depending on the type of services requested.

The "rendering provider" is the provider requesting the prior authorization vs. Is that correct? Can you edit the servicing provider after it's submitted? No, once a request is submitted, no additional changes can be made to the request. Is this limited to prior authorizations or can requests for additional services be completed through Availity? This is limited to prior authorizations only. Can a specialist submit a prior authorization or only the primary care doctor?

Can prior authorizations be retro? Authorizations for procedures can be submitted by either a specialist or a PCP. They should not be retro as they need to be approved before the service is performed. Can prior authorization requests be requested for inpatient, outpatient, and specialty office visits? Office visits would be a referral. Admissions and services are subject to prior authorization. How can I use the Availity authorization dashboard? Can we filter by CPT code? Are the uploads.

PDF only? Availity accepts several different file types. The different types of files are noted on the attachments page. Files must be in doc, docx, gif, htm, jpg, pdf, png, ppt, pptx, tif, txt, xls or xlsx format, no more than 10 files may be added. Is there an easy way to pin the transaction IDs to my Availity dashboard?

Availity Client Services can use other information to locate the prior authorization request if you call for assistance and don't have the transaction ID for the request. We're an ambulance company that provides air and ground services. We send our records through email and mail to Premera and Premera BlueCard. Are we able to send these records through Availity? If Premera isn't listed, do we need to contact the client services? What does the red triangle with the exclamation in the dashboard mean?

This is a message from the payer. If you hover over it, you'll see specific details. What if both provider sections are the same provider? Currently, you'll need to enter the provider's NPI again. We'll work on a future enhancement, so you only need to enter it one time. Will we be able to authorize medications through Availity or is that only for procedures? Medical drugs such as infusions can be requested in Availity.

View all pharmacy drugs requiring approval and how to request approval. What is Premera's timeframe to complete a prior authorization? Authorization requests are submitted to Premera in real-time. We typically respond to requests within 5 days, but it may take up to 15 days if we need additional information.

Do you have to have the provider on your account to follow up on prior authorization requests? You can manually enter provider information, so adding them to your account via the Add Providers process on the Manage My Organization page is optional.

However, adding them helps you choose them from the Select a Provider drop down which will auto-fill their information. Do you ever get an automatic approval or do they all pend for review?

Yes, some requests are auto-approved. Some services can be auto-approved based on the provider's TIN or service s and diagnosis es being requested. In this case you won't be required to provide additional information. For the Authorization Inquiry page, how long does it take for a prior authorization completed by phone or fax to be loaded? We don't take prior authorizations by phone.

The speed of loading a faxed request completely depends on the volume of faxes received. Submitting online through Availity gives you a faster response. You can upload handwritten notes as a. PDF and attach it to your request. We can accept all types of files, including doc, docx, gif, htm, jpg, pdf, png, ppt, pptx, tif, txt, xls or xlsx. Call Care Management at , option 3 AK: , option 3. On the code check feature if a code requires review, but doesn't need it in certain situations i.

The tool will do auto authorizations based on a specific code and diagnosis being submitted. As for stopping them, the prior authorization process flow won't stop the requester. Does the code check tool provide member-specific benefit information for prior authorizations? The stand-alone code check tool doesn't provide member-specific benefit information see screenshot below. The prior authorization checks to see if a code requires prior authorization and does include member-specific benefit information about the member's referral requirements and out-of-network benefits.

I work at a residential substance abuse facility. We use ICD codes, not procedure codes. How does that work in Availity?

This would be an inpatient prior authorization request and we would accept ICD diagnosis codes. What happens if you have more than three diagnosis codes?

Currently, the Availity tool only accepts 3 diagnosis codes. If you have more than three, you can include the additional diagnosis codes in the Provider Notes section. What if I don't have a procedure code to add to my request? For inpatient notification requests, you don't need to add a procedure code. There will not be one for Lower Level of Care admissions. Can I submit a Premera PCP referral request to a specialist on Availity or is it only for prior authorization requests? At this time, it's for prior authorizations only.

Providers can only submit prior authorizations through Availity for Premera plans. We're not using Availity for PCP referrals yet. Does this replace referral authorization submissions via Premera's current secure portal for Premera Medicare Advantage? Premera Medicare Advantage continues to use Advantasure. Can I submit a referral through Availity for Amazon and Microsoft patients? No, we're not currently submitting referrals through Availity. Can this be used for retroactive prior authorization submissions?

Prior authorization needs to happen before the service is performed; after that you would submit a claim. What about Evolent and Advantasure secure tools? Providers will continue to use OneHealthPort's secure single sign-on process to access Evolent, Advantasure, Availity, and other health plan provider portals.

If requesting services through Availity, you'll be directed to complete the request through AIM or eviCore. Do I submit prior authorizations through Availity for high-tech imaging? Can we submit through Availity instead, or do we still need to submit through eviCore? If you submit your requests through eviCore today, you'll continue to submit through eviCore. Do prior authorizations for individual plans go through Availity now? No, you will need to continue to go through Evolent secure portal for individual plans.

Does everyone have access to AIM? It's not listed on my account. AIM is a third-party vendor for certain types of services. No need to wait for mail delivery. Now you can access letters right from the Availity dashboard. Learn more about it. Digital authorization status letters PDF. When you submit a prior authorization request for certain services, we may pend your request for additional clinical information.

We may ask you to complete a clinical questionnaire. Answer a few questions and you may get an approval on the spot. The Aetna provider portal on Availity helps you spend less time on administration so you can focus more on patient care.

You get a one-stop portal to quickly perform key functions you do every day. If your practice already uses Availity, simply contact your Availity administrator to request a username.

If your practice is new to Availity, you can use the registration link below to set up your account. Set up Availity account. We cover how to register for the portal as well as all the tools and resources Availity has to offer. Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates Aetna.

Also of interest:. Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. The information you will be accessing is provided by another organization or vendor. If you do not intend to leave our site, close this message. Each main plan type has more than one subtype. Some subtypes have five tiers of coverage.

Others have four tiers, three tiers or two tiers. This search will use the five-tier subtype. It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan.

Do you want to continue? The Applied Behavior Analysis ABA Medical Necessity Guide helps determine appropriate medically necessary levels and types of care for patients in need of evaluation and treatment for behavioral health conditions.

Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any matters related to their coverage or condition with their treating provider. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.

Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered i. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary.

Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose. Copyright by the American Society of Addiction Medicine. Reprinted with permission. No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept".

See Aetna's External Review Program. All Rights Reserved. You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins CPBs solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. State Street, Chicago, Illinois Applications are available at the American Medical Association Web site, www. Go to the American Medical Association Web site. Department of Defense procurements and the limited rights restrictions of FAR CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose.

No fee schedules, basic unit, relative values or related listings are included in CPT. The responsibility for the content of this product is with Aetna, Inc. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona.

Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services.

This information is neither an offer of coverage nor medical advice. It is only a partial, general description of plan or program benefits and does not constitute a contract.

In case of a conflict between your plan documents and this information, the plan documents will govern. Working with us. Join our network. Confirm patient eligibility Precertification lists and CPT code search. Existing health care professionals. Availity provider portal Update your data Utilization management Provider referral directory. Electronic claims. Disputes and appeals. Cost estimator and fee schedules. Pharmacy claims. Dental claims. Pharmacy services.

Update pharmacy data. Find prescription drug coverage. Clinical policy bulletins. Clinical policy bulletin overview Medical clinical policy bulletins Dental clinical policy bulletins Pharmacy clinical policy bulletins. Medicare resources. Education, trainings and manuals. Overview Educational webinars Provider manuals Behavioral health trainings. State regulations Federal regulations. News and Insights.

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