Workflow Navigator

The Workflow Navigator is intended to help providers quickly get to the right section on a payer website for pre-service or admission notification information. With increasing pre-service demands, providers are finding it challenging to work across multiple payer websites and quickly access the needed information. OneHealthPort developed this tool in partnership with the Pre-Auth Work Group. OneHealthPort will continually update this information based on payer information and provider feedback.

Suggestions? Feedback? Please complete the Feedback Form. Your input is important to us!

 

Select the health plan and type of information you need, and then click Submit.

Glossary

Service Category Definitions

Medical

Services covered under a member’s medical benefit

Advanced Imaging

Services related to radiological studies

Behavioral/Mental Health

Services addressing the behavior and/or mental health of a patient

General Pharmacy

Medications covered under a member’s pharmacy benefit

Carved Out Service

This is provided by an outside service. 

Link Definitions

Coverage Requirements

Information related to a health plan’s Utilization Review requirements associated with a specific service that will cause a denial or will impact reimbursement of a service, to include but not limited to:

  • Is a pre-auth required?
  • What are any payer/plan coverage restrictions, e.g.  type of rendering providers, site of care/place of service, etc.?  This will include specialty pharmacy specific restrictions if/as appropriate.
  • Will a pre/post-service medical necessity review be conducted?
  • Does the requested medication need to be purchased from a speciality pharmacy?
  • Are there any excluded or investigational services that are not included in a patient’s benefit plan?

Clinical Review Criteria

Information related to written screens, decision rules, medical protocols, or guidelines used by the carrier as an element in the evaluation of medical necessity and appropriateness of requested admissions, procedures, and services under the auspices of the applicable health plan.

Pre-Service Request Status

Status information about a submitted pre-service request

Pre-Service Review Request

Interactive form and/or process that the provider would complete and submit when requesting a pre-service review

Unlisted Procedures

  • Phone number for answering questions about an Unlisted Procedure, and 
  • Supporting documentation that needs to be submitted with any Unlisted Procedure