Traditional prior authorization
Prior auth exists so that carriers have confidence that large claims satisfy the Medically Necessary provisions of the Plan Document.
In traditional health plans, the flow of prior authorizations works like this:
The system is administratively complex, especially for the provider who has to coordinate scheduling, deal with authorization, and still wait to get paid. This system generally does not work without a network contract with the provider, as providers will not be willing to do all of this work for uncertain payment.
Cash pay process
To solve for this problem, Yuzu has developed a Cash Pay Pre-Certification process. This pre-certification process is designed to get medical certification while allowing the patient to present as self-pay.
Pre-certification threshold
When Yuzu works with Care Coordinators, the plans are set up around Coordinated Care. Coordinated Care recognizes that there is high trust between the Plan and the member and provider. Thus, Yuzu tries to minimize the number of pre-certifications that need to be done while maintaining the pre-certification requirement for high-dollar cases where the carrier would need to see third-party verification of expenses.
The threshold for Coordinated Care pre-certifications (the topic of this guide) is care Cases with a cost over $10k. Some examples:
Surgeries where the total cost is over $10k, even if none of the itemized expenses (e.g. facility fee, professional fee, anesthesia) cost over $10k by themselves.
Recurring infusions or radiation therapy where singular visits or infusions may cost under $10k, but the total cost over the expected number of treatments is over $10k.
Sometimes the hardest part of figuring out if something needs pre-certification is figuring out the cost. This is why Yuzu always recommends helping the member get a Good Faith Estimate for any events that are expected to be large.
Reach out to Yuzu if you are unsure if a case needs pre-certification to be paid on a cash card.
Information needed for a pre-certification
To do a prior authorization, Yuzu will need some of the same information that a traditional pre-certification would require. This includes:
Medical notes from the referring doctor (the doctor who is recommending the treatment).
Medical records regarding the patient’s diagnosis and previous treatments.
A description of services to be performed — a Good Faith Estimate satisfies this requirement — and the location the services will be performed at.
Generally, this information should be requested from the referring provider which is not always the same as the rendering provider who will provide the service being certified.
Example: if a patient needs a hysterectomy, notes from their DPC or OBGYN will be enough unless the type of hysterectomy being requested is excessively complicated to require notes from the surgeon.
Example: if a patient needs an ortho procedure, notes from a physical therapist or primary care doc could be enough, but if the procedure is excessively complicated then additional documentation might be requested from the surgeon’s consultation.
One issue coordinators run into frequently with these requests is that providers are not used to sharing notes with third parties or going through standard pre-cert processes for self-pay patients. In some cases, patients have been denied self-pay rates when the rendering provider became aware that a patient had insurance.
Thus, it is always advised to try to get notes from the referring provider and from patient portals rather than by asking for notes from a provider as a third-party.
Example of specific notes to look for when reviewing records to see if it would suffice: SOAP notes, H&P, History of Present Illness, treatment plan.
Submitting pre-certification information to Yuzu
Submit information to Yuzu by creating a Case, or adding it to the already existing case in the portal, and then notifying Yuzu over Slack that the case was created. The Case should be connected to the member.
Upon receipt, we will take a quick look at the documentation and get working on submitting it over to the appropriate pre-certification vendor. All attachments should be added to the case, and any back and forth communications involving health data should happen within the secure Yuzu portal.
Timeline
You can expect a decision on a pre-cert within 1 week of getting information to Yuzu. Historically, 95% of coordinated pre-certs have been approved.
If the case is urgent (requires <1 week turnaround) please reach out to Sara on Yuzu’s claims team.