Overview
Yuzu is not a clinical organization. If a plan has a Utilization Management solution for submitting prior authorization, they will be the ultimate source of truth for prior authorization timelines, statuses, and appeals.
Our role in answering if a prior authorization necessary
Yuzu’s role is to maintain the list of services that will require prior authorization and direct providers to the relevant prior authorization vendor when it is deemed potentially necessary. These lists are updated intermittently and vary by solution. Yuzu is not liable for the accuracy of the list of services and the Utilization Management solution should be viewed as the ultimate source of truth.
On the “Benefits” tab for a Plan we flag when a code is on one of these lists. This also includes other important parameters such as a dollar limits. Users can access these lists to verify if a code is on the list.
Our role in receiving prior authorizations
We receive prior authorizations over EDI daily from all Utilization Management partners. These contain the unique identifier, member demographic, provider information, service information, and decision status.
For a group, all relevant pre-certs can be found in the “Pre-certs” tab which shows the pre-cert number, status, patient name among other information. If a detail about these prior authorizations is incorrect, Yuzu cannot make changes. The Utilization Management vendor needs to be reached out to correct their mistake. For a member, the “Pre-cert” tab with all the relevant pre-certs.
The five statuses are: Approved, Denied, Pending, Partially Approved, Cancelled. Partially Approved means the UM vendor approved only part of what the provider asked for. Either some codes were approved and others denied, or fewer units were approved than were requested. These claims are reviewed line by line.
For pending prior authorizations (i.e., prior authorizations that are not yet approved or denied but are in the process of review by the Utilization Management vendor), the Utilization Management will need to be contacted for timelines and escalations. The member or provider need to be the advocate for these requests to go through frequently. The TPA, Plan Designer, Broker are not given the same escalation pathways unfortunately.
Matching prior authorizations to claims and adjudicating
Yuzu matches prior authorizations to both a member’s coverage and claims automatically. Coverage matching works by matching the demographic information in the portal against the prior authorization. Claim matching works by looking at the approved procedure and diagnosis codes, dates of services and providers. The logic is more complex on the claims side to take a more comprehensive approach but it is not a perfect system: the prior authorization we receive is not always going to match the claim. Details on reprocessing requests below.
For a claim where a pre-cert is required but missing, the claim is pended for manual review. ER and urgent care waive the requirement. For facility claims, a mismatch between certified and billed units also sends the claim to manual review.
Reprocessing claims after a change to a prior authorization
For claims that need to reprocessed because a prior authorization came in after a prior adjudication or a detail about a prior authorization changed, the best route is to create a case as Plan Designer with the prior authorization and claim attached to the case. Title: Prior Authorization Reprocessing Request: {Claim Number}”
If you are a broker, provider or member, submit your request to claims@yuzu.health with the prior authorization and claim number included.
Escalating a denied prior authorization
Escalations for denied prior authorizations will need to be handled by the member or provider. The TPA, Plan Designer, Broker are not given the same escalation pathways unfortunately. These vendors will need to be contacted over the phone which is included on the member’s ID card.
Requests to waive a prior authorization
These are reviewed case-by-case. Examples include: the prior TPA didn't require one, the provider was told it wasn't needed, a preventive screening. The best route is to create a case as Plan Designer. Title: Waive prior authorizationt: {Claim Number (if applicable)}”
If you are a broker, provider or member, submit your request to claims@yuzu.health with the relevant details included.
Vendor details
Cigna Pre-certification (TruCare): On all plans with Cigna as the Network, Cigna’s Utilization Management solution, TruCare, handles prior authorizations. Escaltions for timeline will need to run through Cigna.
When a denial occurs, Cigna sends a letter to both the member and the provider. This document will provide the most insight that can be supplied as to “why” something was denied. We, as the administrator do not have the ability.
MedWatch: For some non-Cigna plans, MedWatch runs the prior authorization process. MedWatch sends us “Pending” certifications so the user can have visibility when a pre-certification process has been kicked off without needing to contact MedWatch directly.
EHG (Engaged Health Group): For some non-Cigna plans, EHG runs the prior authorization process. EHG sends us “Pending” certifications so the user can have visibility when a pre-certification process has been kicked off without needing to contact EHG directly.
Prior authorization and cash pay
When a plan is Cash Pay, the rules of prior authorization are different. Details on the process in this doc: https://yuzu.health/docs/guides/prior-authorization-cash-pay