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Utilization Management (UM) Specialist Role and Systems Training – Prospective Review v.1.0

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Introduction & Norms

To help create a productive and respectful training environment, please observe the following:

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Attendance & Time Management

Attend all scheduled sessions.
Notify your trainer if you miss any training.

Communication Standards

Raise your hand prior to unmuting.
Let your trainer know if you step away.

Course Completion

Complete all required training prior to the end of training.

Engagement & Interaction

Actively participate in all activities.
Follow all trainer directions.

Training Environment

Use a quiet, distraction-free workspace.
Give full attention to training.

Professionalism & Respect

Be respectful and professional.
Help create a collaborative learning space.

Failure to follow these training expectations may be escalated to your supervisor.

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] We will start with an introduction and the training session norms.

[Introduce yourself and producer including first and last name and 1-2 sentences about your relevant training].

As the facilitator, I will be leading us through this training, which includes direct instruction, knowledge checks, demonstrations, real-time practice activities, and scenarios.

As I facilitate, our producer will be working in the background to ensure everything runs smoothly and will also be monitoring the chat for any questions you may have.

[At this point, introduce any Subject Matter Experts present and anyone else helping to run the training. Post your name, the date, and the name of the training into the chat.]

[Example chat post: "Facilitator: Jane Smith | Producer: Joe Smith | Date: March 13, 2025 | Training: Utilization Management (UM) Specialist Role and Systems Training – Prospective Review "]

To ensure an optimal training experience, we kindly ask you to keep a few things in mind:

Please arrive on time for each segment and remain in training for the whole session.

If you miss a session, notify the training team by email, and separately, email your supervisor.

[Producer: Paste facilitator and producer emails in the chat.]

Please use our chat or the Teams Raise your hand feature if you have a question.

If you need to step away for a moment, please let us know.

You must complete all components of the training session for credit.

Be an active participant and try to minimize any distractions.

Join training in a quiet, distraction-free environment.

It is important to respect each other and the learning environment as we are all here to learn; there are no silly questions.

Just a reminder, we are planning on recording this training for you to access in the future if needed, so long as there are no objections. We’ll pause now in case anyone would like us to not record.

[Allow 5 seconds]

Thank you all for agreeing to record this session. We will start the recording now.

To better understand who is attending training today, please share in the chat how long you have been with this company.

[Pause for responses and respond to answers]

Thank you for sharing. As we continue, keep in mind that everyone's level of experience is valuable in this training environment.

[Advance slide]

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Participant Guide

Supports your learning throughout the training
Includes discussion sections, planned activities, and knowledge checks
Provides Notes section on each page for your ideas and reminders
Includes Course Key icons to guide you:

Gears = Activity or discussion
Pen = Notes section
Light bulb = Reflection prompt
Stop sign = Wait for facilitator direction

3

Remember, save your own copy.

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] Let’s take a moment to go over your Participant Guide.

This guide will support your learning throughout this training. You’ll use it to follow along during discussions, complete activities, and check your understanding with knowledge questions.

Each page has a Notes section, so feel free to jot down key takeaways, ideas, or questions you want to revisit later.

If you are planning to use the participant guide digitally, before you start typing in the guide, make sure you save your own copy. To do that, go to File, then Save As, choose a location on your computer, and click Save.

You’ll also see several icons throughout the guide that help you navigate the material: the gears icon tells you it’s time to participate, such as a discussion, roleplay, or system walkthrough, the pen icon marks a spot for your notes, and the light bulb icon means there’s a reflection question to think through.

When you see the stop sign, pause and wait for direction before moving forward. This helps us all stay together during the session.

Keep your guide handy because you’ll be using it throughout the course.

[Advance slide]

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Agenda

Welcome
Timelines
Medical Codes
Request Profile Codes
Request Profile Code Scenarios
Creating an Authorization in CareRadius
Prospective Review Scenarios
Wrap Up

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Objectives

Ensure completeness of medical documentation and adherence to workflow timelines
Apply common medical terminology and coding systems such as Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and International Classification of Diseases (ICD-10) within request profiles
Identify request profile codes and their function within the review process
Recall how to create authorizations in CareRadius

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Section One:�Timelines

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Timelines for Pre-authorizations/Authorizations

Proprietary and Confidential

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We will issue determinations on at least:

1.______ of all requests for pre-authorization/authorization within ______

business days following receipt of the request and all required information.

2.______ of such requests within ______ business days following receipt of the request and all required information.

3.______ of all urgent authorizations, excluding those requiring peer review or factual determination, will be processed within ______ business day. Exclusions will be processed within _____ business days.

Type your answers in chat!

Answer Bank: 90%, 100%, one, two, five

100%

90%

100%

two

five

one

two

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] Let’s start with the timelines for pre-authorizations and authorizations. I know we haven’t gone over these yet but take your best guess at what you think goes into these blanks based on the context. I will read each sentence, and you will type your answers in chat. The answer bank consists of 90%, 100%, one, two, and five.

[Pause for responses]

Number one, we will issue determinations on at least ______ of all requests for pre-authorization/authorization within ______ business days following receipt of the request and all required information. Type your two answers in chat.

[Advance for animation]

The answers are 90% and two, so we will issue determinations on at least 90% of all requests for pre-authorization/authorization within two business days following receipt of the request and all required information.

Number two, we will issue determinations on ______ of such requests within ______ business days following receipt of the request and all required information. Type your two answers in chat.

[Advance for animation]

The answers are 100% and five, so we will issue determinations on 100% of such requests within five business days following receipt of the request and all required information.

Number three, ______ of all urgent authorizations, excluding those requiring peer review or factual determination, will be processed within ______ business day. Exclusions will be processed within _____ business days.

[Advance for animation]

The answers are 100%, one, and two, so 100% of all urgent authorizations, excluding those requiring peer review or factual determination, will be processed within one business day. Exclusions will be processed within two business days.

Great job! Now, let’s move on to timelines for referrals.

[Advance slide]

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Timelines for Referrals

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Type your answers in chat!

Answer Bank: 90%, 100%, one, two

We will issue a referral authorization or denial following the date of receipt of a request for a referral, on at least:

______ of all requests within ______ business day.
______ of all requests within ______ business days.
______ of all urgent referrals, excluding those requiring peer review or factual determination, will be processed within ______ business day. Exclusions will be processed within _____ business days.

100%

90%

100%

one

two

one

two

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] Just like the previous slide, I will read each sentence, and you will type your answers in chat. The answer bank consists of 90%, 100%, one, and two.

[Pause for responses]

Number one, we will issue a referral authorization or denial following the date of receipt of a request for a referral, on at least ______ of all requests within ______ business day. Type your two answers in chat.

[Advance for animation]

The answers are 90% and one, so we will issue a referral authorization or denial following the date of receipt of a request for a referral, on at least 90% of all requests within one business day.

Number two, we will issue a referral authorization or denial following the date of receipt of a request for a referral, on ______ of all requests within ______ business days. Type your two answers in chat.

[Advance for animation]

The answers are 100% and two, so we will issue a referral authorization or denial following the date of receipt of a request for a referral, on 100% of all requests within two business days.

Number three, ______ of all urgent referrals, excluding those requiring peer review or factual determination, will be processed within ______ business day. Exclusions will be processed within _____ business days.

[Advance for animation]

The answers are 100%, one, and two, so 100% of all urgent referrals, excluding those requiring peer review or factual determination, will be processed within one business day. Exclusions will be processed within two business days. Great job!

[Advance slide]

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Knowledge Check 1

Enter your answer into the chat.

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We will issue determinations on 100% of requests for pre-authorizations/authorizations within five business days following receipt of the request and all required information.

T

True

F

False

?

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

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Section Two:�Medical Codes

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What is medical coding?

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Medical coding is the translation of a doctor’s documentation into a set of standardized codes. �These codes help systems communicate and make sure providers get paid.

Beneficiary visits provider

Provider documents visit

Medical coder �assigns codes �and submits claim

PGBA processes the claim and notifies the provider and beneficiary of the outcome

What is medical coding?

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script] Let's start with the basics. Who can tell me what they think medical coding might be?

[Pause for responses]

Those are great thoughts!

[Advance for animation]

Medical coding is essentially a translation system that converts healthcare services into a universal language of codes. Think of it as transforming the story of a patient's healthcare visit into a standardized format that can be understood by healthcare providers, insurance companies, and billing systems across the country.

Let me give you a simple example.

[Advance for animation]

When a patient visits their doctor for a sore throat,

[Advance for animation]

the doctor might diagnose them with strep throat and prescribe antibiotics. Instead of writing out "strep throat" and "antibiotic prescription" on a claim form,

[Advance for animation]

the medical coder assigns specific codes. They might use J02.0 for the strep throat diagnosis, 99213 for the office visit and perhaps another code for the throat culture they performed before submitting the claim.

[Advance for animation]

After the medical coder submits the claim, PGBA processes the claim and notifies the provider and beneficiary of the outcome.

These codes tell the entire story of that visit in a standardized way.

[Advance slide]

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Why Medical Coding Matters for UM Specialists

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Reviewing referrals and authorizations
Verifying medical documentation
Creating authorizations

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Code Types

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Diagnosis Code (DX)

Procedure or Treatment Code (TX)

ICD-10

International Classification of Diseases, Tenth Revision
Describe illness, condition or injury
Three to seven characters

Start with a letter
Include a decimal point

CPT

Current Procedural Terminology
Identify medical services and procedures
Five-digit numeric code
Six sections with each relating to a particular type of procedure or healthcare service

Healthcare Common Procedure Coding System
Pronounced hick-picks
Identify medical procedures, supplies, and services
Five characters long

Start with a letter
Four numbers follow letter

HCPCS

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] First, let’s go over code types. There are diagnosis codes and procedure or treatment codes. Diagnosis codes are often abbreviated as DX, and procedure or treatment codes are abbreviated as TX. As the names suggest, diagnosis codes describe an illness, condition, or injury, whereas procedure or treatment codes identify the medical services, procedures, and supplies needed to treat the patient. When working with referral and authorization forms, you will see one to four diagnosis codes and at least one treatment code.

There are three types of medical codes you need to know: ICD-10, CPT, and HCPCS. ICD-10 is a diagnosis code, while CPT and HCPCS are procedure codes. Now, let’s look at the details of each code type.

[Advance for animation]

First up is our category of diagnosis codes. ICD-10, which stands for International Classification of Diseases Tenth Revision, codes describe an illness, condition, or injury. They are always three to seven characters long, start with a letter, and include a decimal point.

[Advance for animation]

Next is the first of our two types of procedure codes. CPT is short for Current Procedural Terminology, and these codes identify medical services and procedures. CPT codes always have five numbers and are divided into six main sections. Each section relates to a particular type of procedure or healthcare service.

[Advance for animation]

HCPCS, pronounced hick-picks, stands for the Healthcare Common Procedure Coding System. HCPCS codes identify medical procedures, supplies, and services. They also have five characters, but they begin with one letter followed by four numbers.

Note that both CPT and HCPCS codes identify medical services and procedures, but HCPCS codes also identify medical supplies.

[Advance slide]

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ICD-10 | CPT | HCPCS

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Type your answers in chat! Answer Bank: ICD-10, CPT, HCPCS

____________ codes identify medical procedures, supplies, and services. They are five characters long, but they are signified by their first letter with four subsequent numbers.
____________ codes describe illness, condition, or injury. They contain three to seven characters, start with a letter, and include a decimal point.
____________ codes identify medical services and procedures. They are always five numbers and are divided into six main sections. Each section relates to a particular type of procedure or healthcare service.

ICD-10

HCPCS

CPT

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] Let’s identify the codes! Here is the description of the three code types. Type your answers in chat, and remember, the answer bank consists of ICD-10, CPT, and HCPCS.

[Pause for responses]

Time to go over the answers! Number one, _______[Blank] codes identify medical procedures, supplies, and services. They are five characters long, but they are signified by their first letter with four subsequent numbers.

[Advance for animation]

The answer is HCPCS. Number two, _______[Blank] codes describe illness, condition, or injury. They contain three to seven characters, start with a letter, and include a decimal point.

[Advance for animation]

The answer is ICD-10. Number three, _______[Blank] codes identify medical services and procedures. They are always five numbers and are divided into six main sections. Each section relates to a particular type of procedure or healthcare service.

[Advance for animation]

The answer is CPT.

[Advance slide]

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Identify Codes

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Type ICD-10, CPT, or HCPCS in chat!

ICD-10

CPT

HCPCS

Z00.00

Medical Exam

99214

Office Visit

Z00.00

Medical Exam

99214

Office Visit

R07.9

Chest pain

R07.9

Chest pain

J3301

Injection

J3301

Injection

36415

Blood Draw

36415

Blood Draw

K0001

Wheelchair

K0001

Wheelchair

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] Moving on… Let’s apply our knowledge of codes to identify codes. Decide if each code is an ICD code, a CPT code, or a HCPCS [pronounced hick-picks]. Type ICD, CPT, or HCPCS in the chat as we go!

[Advance for animation]

Our first code is Z00.00, which is general medical exam. Is that an ICD, CPT, or HCPCS code? Type your answer in the chat.

[Pause for responses. Advance for animation twice]

ICD-10 is correct! ICD codes start with a letter and have a decimal point.

[Advance for animation]

Our next code is 99214, which is an office visit. Is that an ICD, CPT, or HCPCS code? Type your answer in the chat.

[Pause for responses. Advance for animation twice]

99214 is a CPT code! Remember, CPT codes are five numbers.

[Advance for animation]

Our next code is R07.9, which is chest pain. Is that an ICD, CPT, or HCPCS code? Type your answer in the chat.

[Pause for responses. Advance for animation twice]

ICD-10 is correct! ICD codes start with a letter and have a decimal point.

[Advance for animation]

Our next code is J3301, which is an injection. Is that an ICD, CPT, or HCPCS code? Type your answer in the chat.

[Pause for responses. Advance for animation twice]

HCPCS is correct! HCPCS codes start with a letter and have four numbers after the letter.

[Advance for animation]

Our next code is 36415, which is a blood draw. Is that an ICD, CPT, or HCPCS code? Type your answer in the chat.

[Pause for responses. Advance for animation twice]

CPT is correct! CPT codes are five numbers.

[Advance for animation]

Our last code is K0001, which is a wheelchair. Is that an ICD, CPT, or HCPCS code? Type your answer in the chat.

[Pause for responses. Advance for animation twice]

HCPCS is correct! HCPCS codes start with a letter and have four numbers after the letter.

Great job with identifying ICD-10, CPT, and HCPCS codes!

[Advance slide]

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Knowledge Check 2

Enter your answer into the chat.

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Which type of code is F32.3?

A

CPT

B

ICD-10

C

HCPCS

D

None of the above

?

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

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Knowledge Check 3

Enter your answer into the chat.

17

Which type of code is 99456?

A

CPT

B

ICD-10

C

HCPCS

D

None of the above

?

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

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Knowledge Check 4

Enter your answer into the chat.

18

Which type of code is S9122?

A

CPT

B

ICD-10

C

HCPCS

D

None of the above

?

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

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Section Three:�Request Profile Codes

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Medical Priority Terms

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Term

Emergency Condition

Urgent Condition

Non-Urgent Condition

Routine Procedure

Elective Procedure

Definition

This does not require immediate medical attention, and the beneficiary can schedule it at a convenient time. It does not pose a serious risk to health if the beneficiary receives treatment later.
This refers to a serious, life-threatening medical condition that requires immediate care to prevent severe harm or death. It often requires an ambulance and emergency room treatment.
This is a common and regularly performed medical process that follows standard medical guidelines and helps diagnose, monitor, or treat a condition. The beneficiary typically schedules this.
The beneficiary typically plans this procedure in advance because it is not an emergency.
This condition requires care soon, usually within 24 hours, to prevent complications. However, it is not immediately life-threatening.

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] Before we get into request profile codes, we’re going to first review some medical terminology that you learned in the Introduction to Medical Terminology WBT. This will refresh your memory and help frame this request profile codes section. We’ll begin with medical priority terms. You will match the definition to the term by typing the letter of the definition in the chat. Let’s get started!

Number one is emergency condition. Type the letter of the corresponding definition in chat.

[Pause for responses. Advance for animation]

B is correct! An emergency condition refers to a serious, life-threatening medical condition that requires immediate care to prevent severe harm or death. It often requires an ambulance and emergency room treatment. Number two is urgent condition. Type the letter of the corresponding definition in chat.

[Pause for responses. Advance for animation]

E is correct! An urgent condition requires care soon, usually within 24 hours, to prevent complications. However, it is not immediately life-threatening. Number three is non-urgent condition. Type the letter of the corresponding definition in chat.

[Pause for responses. Advance for animation]

A is correct! A non-urgent condition does not require immediate medical attention, and the beneficiary can schedule it at a convenient time. It does not pose a serious risk to health if the beneficiary receives treatment later. Number four is routine procedure.

[Pause for responses. Advance for animation]

C is correct! A routine procedure is a common and regularly performed medical process that follows standard medical guidelines and helps diagnose, monitor, or treat a condition. The beneficiary typically schedules this. Number five is elective procedure.

[Pause for responses. Advance for animation]

D is correct! An elective procedure is a procedure that the beneficiary typically plans in advance, because it is not an emergency.

Great job! Let’s move on to common medical procedures.

[Advance slide]

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Common Medical Procedures

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Term

X-Ray
Magnetic Resonance Imaging (MRI)
Computed Tomography (CT) Scan
Ultrasound
Endoscopy
Echocardiogram
Dialysis

Definition

Procedure in which a tube with a camera is inserted into the body to examine internal organs
Diagnostic imaging test that uses sound waves to create real-time images of internal organs and tissues
Medical treatment that removes waste, extra fluid, and toxins from the blood when the kidneys are no longer able to function properly
Uses strong magnets and radio waves to create detailed images of organs, soft tissues, and the nervous system
Takes cross-sectional x-ray images from different angles to provide a detailed look inside the body
Diagnostic test that uses ultrasound waves to create images of the heart and check its function
Diagnostic test that uses a small amount of radiation to create images of the inside of the body, especially bones

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] Just like the last slide, you will match the definition to the term by typing the letter of the definition in chat. Let’s get started!

Number one is x-ray.

[Pause for responses. Advance for animation]

G is correct! X-ray is a diagnostic test that uses a small amount of radiation to create images of the inside of the body, especially bones. Number two is Magnetic Resonance Imaging (MRI).

[Pause for responses. Advance for animation]

D is correct! MRI uses strong magnets and radio waves to create detailed images of organs, soft tissues, and the nervous system. Number three is Computed Tomography (CT) Scan.

[Pause for responses. Advance for animation]

E is correct! A CT scan takes cross-sectional x-ray images from different angles to provide a detailed look inside the body. Number four is ultrasound.

[Pause for responses. Advance for animation]

B is correct! An ultrasound is a diagnostic imaging test that uses sound waves to create real-time images of internal organs and tissues. Number five is endoscopy.

[Pause for responses. Advance for animation]

A is correct! Endoscopy is a procedure in which a tube with a camera is inserted into the body to examine internal organs. Number six is echocardiogram.

[Pause for responses. Advance for animation]

F is correct! Echocardiogram is a diagnostic test that uses ultrasound waves to create images of the heart and check its function. Number seven is dialysis.

[Pause for responses. Advance for animation]

C is correct! Dialysis is a medical treatment that removes waste, extra fluid, and toxins from the blood when the kidneys are no longer able to function properly.

Great job! Let’s move on to medical specialties.

[Advance slide]

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Medical Specialties

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Term

Gynecology
Hepatology
Pulmonology
Rheumatology
Neurosurgery
Ophthalmology
Cardiology
Gastroenterology
Orthopedics
General Surgery

Definition

Covers the entire digestive system
Specializes in liver diseases
Specializes in lung health and breathing disorders
Covers broad surgical procedures (e.g., appendectomy)
Focuses on heart-related conditions
Treats physical injuries and structural issues of joints/muscles
Treats female reproductive system disorders but does not manage pregnancies
Performs surgical procedures on the nervous system
Focuses on autoimmune conditions affecting joints/connective tissues
Medical and surgical treatment of eye diseases
Focuses on kidney diseases (non-surgical management)

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] Just like the last slide, you will match the definition to the term by typing the letter of the definition in chat. Let’s get started!

Number one is gynecology.

[Pause for responses. Advance for animation]

G is correct! Gynecology treats female reproductive system disorders but does not manage pregnancies. Number two is hepatology.

[Pause for responses. Advance for animation]

B is correct! Hepatology specializes in liver diseases. Number three is pulmonology.

[Pause for responses. Advance for animation]

C is correct! Pulmonology specializes in lung health and breathing disorders. Number four is rheumatology.

[Pause for responses. Advance for animation]

I is correct! Rheumatology focuses on autoimmune conditions affecting joints and connective tissues. Number five is neurosurgery.

[Pause for responses. Advance for animation]

H is correct! Neurosurgery performs surgical procedures on the nervous system. Number six is ophthalmology.

[Pause for responses. Advance for animation]

J is correct! Ophthalmology refers to medical and surgical treatment of eye diseases. Number seven is cardiology.

[Pause for responses. Advance for animation]

E is correct! Cardiology focuses on heart-related conditions. Number eight is gastroenterology.

[Pause for responses. Advance for animation]

A is correct! Gastroenterology covers the entire digestive system. Number nine is orthopedics.

[Pause for responses. Advance for animation]

F is correct! Orthopedics treats physical injuries and structural issues of joints and muscles. Number ten is general surgery.

[Pause for responses. Advance for animation]

D is correct! General surgery covers broad surgical procedures such as an appendectomy.

Great job! Let’s move on to levels of care to prepare you to better understand request profile codes.

[Advance slide]

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Request Profile Codes

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UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] From the CareRadius Authorizations training session, you learned about request profile codes and how to create an authorization with them. In these next slides, we’re going to review request profile codes and delve deeper into them.

When building an authorization in CareRadius, the most complicated part is finding the correct request profile code. They start with abbreviations, also known as shortcut codes, such as IP for inpatient, OP for outpatient, HH for home health, and BH for behavioral health. Let’s examine this screenshot of request profile codes for behavioral health as an example.

When you input one of these abbreviations (IP, OP, HH, or BH) and add an asterisk in CareRadius to search for a request profile code, a set of codes will pre-populate, and you can choose the code that corresponds with the authorization. These codes affect billing, and they must align with CareRadius. While they start with BH, they have letters afterward that correspond with their description.

[Advance for animation]

For instance, BH_ECT stands for BH Electroconvulsive Treatment (ECT).

[Advance for animation]

There are also three behavioral codes that are inpatient, so they start with “BH_IP”.

These next slides go into a little more detail on the type of codes you can select and then will give you a chance to practice searching for request profile codes. So, our next step is to log in to CareRadius NP3 environment.

[Advance slide]

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Accessing CareRadius NP3

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Directions:

Navigate to CareRadius NP3.
Enter User ID and Password.
Select LOG IN.

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

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Inpatient (IP) Profiles (1 of 2)

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UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] First, we’ll go over the inpatient (IP) codes. In Request Profile Search, we type “IP*” and then select Search to view all the inpatient codes. The following results appear: Rehab, Emergency Room (ER) Admit, Hospice, Long Term Acute Care (LTAC), Medical, Neonatal Intensive Care Unit (NICU), Notify, SNF, SpineSurg [pronounced spyne-surge], and Surgical.

Now, it’s your turn to practice! In the NP3 environment, type IP* and select Search. This should give you the same list of results that I have here. React with a thumbs up when you have the same codes that are in this screenshot. You have one minute.

[Producer: Set timer for one minute]

Great job! It looks like everyone successfully got a list of inpatient codes! Let’s move on to understanding and practicing with each of these codes.

[Advance slide]

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Inpatient (IP) Profiles (2 of 2)

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Type which code I’m referring to in chat!

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] Take a moment and look over the inpatient codes listed before we begin.

[Pause for a minute]

Now, I am going to describe the codes one by one, and you will type the code I’m referring to in chat. Let’s get started!

This type of admission is for beneficiaries requiring end-of-life care. Enter the code you think fits this in the chat.

[Pause for responses. Advance for animation]

Well done! The answer is IP_HOSPICE for Hospice – Inpatient.

[Advance for animation]

Next, this is considered a routine pre-authorization for a non-emergent inpatient admission. Enter the code you think fits this in the chat.

[Pause for responses. Advance for animation]

Great job! The answer is IP_MEDICAL for Medical Pre-Admission Request.

[Advance for animation]

Next, this applies to infants who are born with intensive medical needs, such as the need for ventilator support. Enter the code you think fits this in the chat.

[Pause for responses. Advance for animation]

Well done! The answer is IP_NICU for Neonatal Intensive Care Unit Admission.

[Advance for animation]

Next, this refers to a prior authorization specifically for spine surgery. Enter the code you think fits this in the chat.

[Pause for responses. Advance for animation]

Good job! The answer is IP_SPINESURG for spine surgery prior auth request.

[Advance for animation]

Next, this typically occurs when a beneficiary is discharged from an acute inpatient hospitalization and requires rehabilitation. For example, a patient who underwent a double hip repair may need acute inpatient rehabilitation and medical support and is able to tolerate at least three hours of therapy per day.

[Pause for responses. Advance for animation]

The answer is IP_REHAB for Acute Rehab Admission – Inpatient.

[Advance for animation]

Next, a beneficiary may be discharged from an acute hospitalization to this facility for continued therapy, such as physical therapy. Typically, only one to two types of therapy are provided, and not every day. These units may also administer one IV infusion and perform basic wound care.

[Pause for responses. Advance for animation]

The answer is IP_SNF for Skilled Nursing Facility Admission.

[Advance for animation]

Next, this refers to an inpatient admission through the emergency room due to a crisis situation.

[Pause for responses. Advance for animation]

The answer is IP_ER_ADMIT for Emergency Admission – Inpatient.

[Advance for animation]

Next, this is a prior authorization request for all other types of inpatient surgeries and does not include spine surgeries.

[Pause for responses. Advance for animation]

The answer is IP_SURGICAL.

[Advance for animation]

Next, a beneficiary may be discharged to this type of facility for extended medical care needs such as ventilator weaning or treatment of third- or fourth-degree wounds. These patients typically have multiple complex medical needs.

[Pause for responses. Advance for animation]

The answer is IP_LTAC for Long-Term Acute Care Hospital – Inpatient.

[Advance for animation]

Last one, this indicates that the hospital is notifying the health plan of a routine inpatient admission, possibly one that was preauthorized earlier in the year. It is not related to behavioral health or maternity care.

[Pause for responses. Advance for animation]

The answer is IP_NOTIFY for notifications that are not related to behavioral health or maternity care.

[Advance for animation]

[Advance slide]

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Outpatient (OP) Profiles (1 of 2)

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[Script:] Now, we’ll go over the outpatient (OP) codes. In Request Profile Search, we type “OP*” and then select Search to view all the outpatient codes. The following results appear: Infusion, EGD or esophagogastroduodenoscopy [pronounced ee-sof-uh-go-gas-troh-doo-oh-den-AH-skuh-pee], Generic Med, Rehab Complex, and Generic Surg.

Now, it’s your turn to practice! In the NP3 environment, type OP* and select Search. This should give you same list of results that I have here. React with a thumbs up when you have the same codes that are in this screenshot. You have one minute.

[Producer: Set timer for one minute]

Great job! It looks like everyone successfully got a list of outpatient codes! Let’s move on to understanding and practicing with each of these codes.

[Advance slide]

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Outpatient (OP) Profiles (2 of 2)

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Type which code I’m referring to in chat!

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] Take a moment again and look over the inpatient codes listed before we begin.

[Pause a minute]

Now, I am going to describe the codes one by one, and you will type the code I’m referring to in chat. Let’s get started!

This refers to any outpatient medical procedure that is not specifically listed in the outpatient profiles, such as a colonoscopy or diagnostic testing. Enter the code you think fits this in the chat.

[Pause for responses. Advance for animation]

Great job! The answer is OP_GENERIC_MED for outpatient medical procedures.

[Advance for animation]

Next, this involves the intravenous infusion of medication. Enter the code you think fits this in the chat.

[Pause for responses. Advance for animation]

Well done! The answer is OP_INFUSION for infusion therapy in an office or infusion suite.

[Advance for animation]

Next, this involves outpatient rehabilitation services such as physical therapy (PT), speech therapy (ST), occupational therapy (OT), or a combination of all three, typically provided at a facility. Enter the code you think fits this in the chat.

[Pause for responses. Advance for animation]

Great job! The answer is OPREHABCOMPLEX.

[Advance for animation]

Next, this is an outpatient procedure commonly referred to as an upper GI scope.

[Pause for responses. Advance for animation]

The answer is OP_EGD. EGD stands for esophagogastroduodenoscopy.

[Advance for animation]

Last one for OP, this includes any outpatient surgical procedures, such as meniscus repairs, hernia repairs, tonsillectomies, arthroscopies, tendon and muscle repairs, and laparoscopic surgeries like gallbladder removal or appendectomy.

[Pause for responses. Advance for animation]

The answer is OP_GENERIC_SURG.

[Advance for animation]

[Advance slide]

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Home Health (HH) Profiles

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There are two Home Health Profiles:

HH_ PPS: All Home Health Requests for a skilled service
HOMEINFUS: A beneficiary receives an intravenous medication in the home

NOTE: There will be a new profile called HH_ Generic coming soon!

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] To pull up home health profiles, type “HH*” in the Code field and then select Search.

There are two home health profiles. We use HH_ PPS for all home health requests for a skilled service. PPS stands for Prospective Payment Service, and it will be on the request. The other profile is HOMEINFUS [pronounced home-in-fyooz], which is the profile for home infusion specialty drug administration. We use this when a beneficiary receives an intravenous medication at home.

Note that there will be a new profile called HH_ Generic coming soon!

Now, it’s your turn to practice! In the NP3 environment, type HH* and select Search. This should give you same list of results that I have here. React with a thumbs up when you have the same codes that are in this screenshot. You have one minute.

[Producer: Set timer for one minute]

Great job! It looks like everyone successfully got a list of home health codes! Let’s move on to behavioral health!

[Advance slide]

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Behavioral Health (BH) Profiles (1 of 2)

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[Script:] Now, we’ll go over the behavioral health (BH) codes. In Request Profile Search, we type “BH*” and then select Search to view all the behavioral health codes. 21 results appear, but we’ll only go over the more frequent ones.

As a general note, all these descriptions for profiles – IP, OP, BH, and so on – are in alphabetical order. If you’re looking for a specific code, keep that in mind.

Now, it’s your turn to practice! In the NP3 environment, type BH* and select Search. This should give you same list of results that I have here. React with a thumbs up when you have the same codes that are in this screenshot. You have one minute.

[Producer: Set timer for one minute]

Great job! It looks like everyone successfully got a list of behavioral health codes! Let’s move on to understanding and practicing with each of these codes.

[Advance slide]

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Behavioral Health (BH) Profiles (2 of 2)

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Type which code I’m referring to in chat!

BH_RTC: Non-emergency admission to a residential treatment center for behavioral health services

RTF_SUD: Routine, non-emergency admission to a residential treatment facility for substance use disorder treatment

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] And one more time, take a moment and look over the inpatient codes listed before we begin.

[Pause a minute]

Just like the other profiles, I am going to describe the codes one by one, and you will type the code I’m referring to in chat. Let’s get started!

This refers to an emergency admission to the hospital for a mental health issue, such as manic-depressive disorder, a suicide attempt, or suicidal ideation. Enter the code you think fits this in the chat.

[Pause for responses. Advance for animation]

Great job! The answer is BH_IP_ER_MH.

[Advance for animation]

Next, this refers to a non-emergency inpatient admission for treatment of substance use disorder. Enter the code you think fits this in the chat.

[Pause for responses. Advance for animation]

Well done! The answer is BH_IP_SUD.

[Advance for animation]

Next, this is a prior authorization request for a routine inpatient admission for a behavioral health diagnosis. Enter the code you think fits this in the chat.

[Pause for responses. Advance for animation]

Great job! The answer is BH_IP_ROUTINE.

[Advance for animation]

Next, this refers to an emergency admission to the hospital for substance use disorder (SUD).

[Pause for responses. Advance for animation]

The answer is BH_IP_ER_SUD.

[Advance for animation]

There are two other codes that you should know.

[Advance for animation]

First, BH_RTC is a non-emergency admission to a residential treatment center for behavioral health services. Second, RTF_SUD refers to a routine, non-emergency admission to a residential treatment facility for substance use disorder treatment.

[Advance slide]

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Looking Up Request Profile Codes (1 of 2)

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Looking Up Request Profile Codes (2 of 2)

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Demonstration One: Looking Up Request Profile Codes

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Activity One: Looking Up Request Profile Codes

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Time for completion: 5 minutes

When finished: Emoji in the chat

Participant Guide: Appendix A, Activity One

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] We will now begin our next activity, which is to look up request profile codes.

In your Participant Guide, select the activity link and follow the steps to complete your activity.

[Producer re-adds the Participant Guide link to the chat, stating: “We will now begin Activity One: Looking Up Request Profile Codes, which you will find steps for in Appendix A of your Participant Guide.”]

We’ll start our timer for 5 minutes, which gives us plenty of time to complete the activity. If you encounter difficulties along the way or have questions that pertain to the activity, use the chat to communicate those, and we’ll assist you.

If you complete the activity before the time is up, we ask that you put an emoji of your choice in the chat.

Are there any questions before we start the timer? [Pause for discussion] Okay, you may begin.

[Facilitator begins the built-in Microsoft Teams Timer and monitors the chat for questions.]

Great job with completing Activity One! Now, we’re going to move on.

[End of Activity - Advance slide]

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Referral Codes and Profile Review Resource

Request profile codes
Descriptions
Included Procedure Codes (CPT/NDC/HCPCS)
Approval Duration
Use cases

Proprietary and Confidential

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[Script:] Let’s take a moment to look at an existing resource in our Content Library, which you can find in the Link Directory of your Participant Guide. In addition, the producer will paste the link into our chat right now.

[Producer pastes referral code and request profile guide link to chat. You can find this in the Link Directory of the Facilitator Guide.]

[Advance for animation]

This guide displays request profile codes, descriptions, procedure codes, approval duration, and use cases, and can serve as an essential reference point for request profile categories.

When working with referral and authorization forms, you will see one to four diagnosis codes and at least one treatment code. Using Ctrl+F, find those same codes in the Included Procedure Codes (CPT/NDC/HCPCS) column of this resource. After locating the procedure code, use the corresponding request profile code when building the authorization in CareRadius.

[Advance for animation]

For instance, if the procedure code on the referral or authorization form is 99221, I will use Ctrl+F to search “99221” in this Referral Codes and Profile Review Resource and then use the corresponding request profile code in CareRadius, which is IP_ER_ADMIT.

Now, let’s play a game. Keep the Referral Codes and Profile Review Resource open, because you’ll need it to play the game!

[Advance slide]

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Practice: Referral Codes and Profile Review Resource (1 of 2)

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Procedure Code		Answer
1.	H0017
2.	99477
3.	72195

Use Microsoft Teams reactions to identify each example’s request profile.

BH_RTF_SUD

IP_NICU

MRI_PELVIS

IP_NICU

BH_RTF_SUD

MRI_PELVIS

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

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Practice: Referral Codes and Profile Review Resource (2 of 2)

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Procedure Code		Answer
1.	76700
2.	E0601
3.	47135

Use Microsoft Teams reactions to identify each example’s request profile.

DME_CPAP

TRANS_LIVER

US_ABD

DME_CPAP

TRANS_LIVER

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

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Knowledge Check 5

Enter your answer into the chat.

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Which request profile code should you select for a home infusion of Remicade?

A

HH_PPS

B

HOMEINFUS

C

OP_INFUSION

D

IP_ INFUSION

?

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

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Knowledge Check 6

Enter your answer into the chat.

40

Which request profile code should you select for a spinal fusion of the lumbar spine 5 (L5) routine request?

A

IP_ ER_ Admit

B

IP_Surgical

C

IP_SpineSurg

D

CT_Lumbar

?

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Section Four:�Request Profile Code Scenarios

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Request Profile Scenario Voting Part One

Vote for a scenario by posting the corresponding emoji in the chat!

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😂

Scenario One: Physical Therapy

😍

Scenario Two: Ventilator Support

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Request Profile Scenario One

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You receive a physical therapy request for a �beneficiary who is not hospitalized.

Next Scenario

Next Slide

A

IP*

B

OP*

C

HH*

D

BH*

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] You receive a physical therapy request for a beneficiary who is not hospitalized. Which abbreviation would you type in the Code field when performing a request profile search? Type the code in chat.

[Pause for responses]

[Advance for animation]

That’s correct! You would type OP*, because physical therapy would be an outpatient service. Now, let’s look at the results after you type OP*.

[Advance for animation]

Which request profile code should you choose?

[Pause for responses]

[Advance for animation]

The correct answer is OPREHABCOMPLEX, because this code is for outpatient rehabilitation services such as physical therapy (PT), speech therapy (ST), occupational therapy (OT), or a combination of all three, typically provided at a facility.

[Advance for animation]

[Instructor: Select the “Next Scenario” button if you haven’t covered Scenario Two. If you have covered Scenario Two, select the “Next Slide” button.]

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Request Profile Scenario Two

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You are entering an authorization for an infant who needs ventilator support.

Next Scenario

Next Slide

A

IP*

B

OP*

C

HH*

D

BH*

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] You are entering an authorization for an infant who needs ventilator support. Which abbreviation would you type in the Code field when performing a request profile search? Type the code in chat.

[Pause for responses]

[Advance for animation]

That’s correct! You would type IP*, because the infant would require inpatient services. Now, let’s look at the results after you type IP*.

[Advance for animation]

Which request profile code should you choose?

[Pause for responses]

[Advance for animation]

The correct answer is IP_NICU. An infant on ventilator support will need to be in the neonatal intensive care unit (NICU).

[Advance for animation]

[Instructor: Select the “Next Scenario” button if you haven’t covered Scenario One. If you have covered Scenario One, select the “Next Slide” button.]

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Request Profile Scenario Voting Part Two

Vote on a scenario by posting the corresponding emoji in the chat!

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❤️

👍

😁

Scenario Three:

Suicide and Depression

Scenario Four:

Severe Burn Treatment

Scenario Five:

Gallbladder Removal

Surgery

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] The same as our last scenario vote, you will vote for a scenario based on its corresponding emoji.

[Advance for animation]

Your first option is scenario three, a scenario about suicide and depression, which you can vote for with a heart emoji.

[Advance for animation]

The second option is scenario four, a scenario about severe burn treatment, which you can vote for with a thumbs up emoji.

[Advance for animation]

The third option is scenario five, a scenario about gallbladder removal surgery, which you can vote for with a smiley face emoji. Post the emoji of the scenario you would like us to begin with in the chat.

[Pause for responses]

[Producer: Count how many votes each emoji received. Based on the count, the one with the most will be the first scenario, the one with the second most will be the second scenario review, and the one with the least number of votes will be the third scenario.]

It looks like scenario ____ is the winner! Followed by scenario _________ in second and scenario ___________ in last place. This is the order we’ll go in to review the scenarios. Thanks for voting!

[Instructor: Select the winning scenario to be directed to the designated slide.]

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Request Profile Scenario Three

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You are entering an authorization for a beneficiary who attempted to commit suicide due to depression and was rushed to the emergency room.

Scenario Menu

Next Slide

A

IP*

B

OP*

C

HH*

D

BH*

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] You are entering an authorization for a beneficiary who attempted to commit suicide due to depression and was rushed to the emergency room. Which abbreviation would you type in the Code field when performing a request profile search? Type the code in chat.

[Pause for responses]

[Advance for animation]

That’s correct! You would type BH* for behavioral health, because the suicide attempt was due to depression, a mental health issue. Now, let’s look at the results after you type BH*.

[Advance for animation]

Which request profile code should you choose?

[Pause for responses]

[Advance for animation]

The correct answer is BH_IP_ER_MH, because this code is for an emergency admission to the hospital for a mental health issue, such as manic-depressive disorder, a suicide attempt, or suicidal ideation.

[Advance for animation]

[Instructor: Select the Scenario Menu button if you haven’t covered Scenario Four or Scenario Five yet. From the menu, select the next scenario based on the order that was voted on. If you have covered Scenario Four and Scenario Five, select the Next Slide button.]

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Request Profile Scenario Four

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You receive a request for a beneficiary to be discharged to a facility for treatment of third-degree burns.

Scenario Menu

Next Slide

A

IP*

B

OP*

C

HH*

D

BH*

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] You receive a request for a beneficiary to be discharged to a facility for treatment of third-degree burns. Which abbreviation would you type in the Code field when performing a request profile search? Type the code in chat.

[Pause for responses]

[Advance for animation]

That’s correct! You would type IP*, because they require inpatient services. Now, let’s look at the results after you type IP*.

[Advance for animation]

Which request profile code should you choose?

[Pause for responses]

[Advance for animation]

The correct answer is IP_LTAC. A beneficiary may be discharged to long term acute care for extended medical care needs such as ventilator weaning or treatment of third- or fourth-degree wounds. These patients typically have multiple complex medical needs.

[Advance for animation]

[Instructor: Select the Scenario Menu button if you haven’t covered Scenario Three or Scenario Five yet. From the menu, select the next scenario based on the order that was voted on. If you have covered Scenario Three and Scenario Five, select the Next Slide button.]

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Request Profile Scenario Five

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You receive a request for a gallbladder removal surgery.

Scenario Menu

Next Slide

A

IP*

B

OP*

C

HH*

D

BH*

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] You receive a request for gallbladder removal surgery. Which abbreviation would you type in the Code field when performing a request profile search? Type the code in chat.

[Pause for responses]

[Advance for animation]

That’s correct! You would type OP*, because gallbladder removal is an outpatient surgical procedure. Now, let’s look at the results after you type OP*.

[Advance for animation]

Which request profile code should you choose?

[Pause for responses]

[Advance for animation]

The correct answer is OP_GENERIC_SURG, because this code is for outpatient surgical procedures, such as meniscus repairs, hernia repairs, tonsillectomies, arthroscopies, tendon and muscle repairs, and laparoscopic surgeries like gallbladder removal or appendectomy.

[Advance for animation]

[Instructor: Select the Scenario Menu button if you haven’t covered Scenario Three or Scenario Four yet. From the menu, select the next scenario based on the order that was voted on. If you have covered Scenario Three and Scenario Four, select the Next Slide button]

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Section Five:�Creating an Authorization in CareRadius

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Essential Fields When Creating an Authorization

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* Contact Name and Phone

From referral/ authorization form

* Contact Method

Select from drop-down choices

* Reference Number

Auto-populates from starting a new authorization

* Fax ID

Required for all authorizations

* Event Classification

Auto-populates from request profile

* Case Type

Auto-populates from request profile

* Reason for Referral

From referral/ authorization form

* Diagnosis Code

From referral/ authorization form

* Request Profile

Select from drop-down choices or search

* Requesting Provider

Must be selected via provider search

* Facility is mandatory for inpatient services

Missing information? Follow up with the provider!

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] When creating an authorization in CareRadius, we must complete several fields every time to ensure the request processes correctly.

These include:

[Advance for animation] The contact name and phone number, which come from the referral and authorization form. If this information is missing, we can just enter the provider name.

[Advance for animation] The contact method, which will be 'Fax’ if the request came through DOMA.

[Advance for animation] The reference number, which auto-populates as soon as you open the new authorization.

[Advance for animation] The Fax ID field, which all authorizations require to ensure they route correctly. If the request comes through phone, we will just enter “1234”.

[Advance for animation] The request profile, which populates once you search for a request profile code and choose the code that corresponds with the authorization.

[Advance for animation] The event classification, which auto-populates from the request profile.

[Advance for animation] The case type, which also auto-populates from the request profile.

[Advance for animation] The reason for referral, which comes from the referral and authorization form.

[Advance for animation] The diagnosis code, which also comes from the referral and authorization form.

[Advance for animation] And the requesting provider.

[Advance for animation] Also, if the service is inpatient entering a facility is mandatory.

If an incoming referral and authorization form appears to be incomplete, then you will be unable to complete these fields properly and should not continue with creating the authorization. In this case,

[Advance for animation]

we always follow up with the provider to obtain the required information. Completing these fields accurately helps ensure the authorization saves and routes correctly through the system.

Now that we covered the information needed when building an authorization, let’s explore how to create one.

[Advance slide]

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Creating a New Authorization in CareRadius (1 of 8)

Activity tab

Central place to view and manage all requests

Basic member information

Verify before building the authorization

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Creating a New Authorization in CareRadius (2 of 8)

Details tab

Also to be verified before building the authorization (date of birth, address, and sponsor name)

52

Details tab

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Creating a New Authorization in CareRadius (3 of 8)

Activity tab
New 🡪 Authorizations
Three key tabs

General Information
Services
Documents

53

v

General Information, Services, and Documentation tabs

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Creating a New Authorization in CareRadius (4 of 8)

1. General Information tab

Contact details

Name, phone, method (typically Fax)

Fax ID (“1234” for phone)
Reference number (auto-generated)
Request Profile

Shortcut codes
Search icon

Event Classification and Case Type (auto-generated from request profile)
Reason for Referral
Diagnosis Code

54

Double-check before submitting for review

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] Within the General Information tab, we enter all the required information for the request. This includes those essential fields we previewed earlier.

[Advance for animation]

The Contact Name, Contact Phone Number, and the Contact Method are the first few fields. For most requests that come through DOMA, fax will be the appropriate contact method to select.

[Advance for animation] We must complete the Fax ID field to save the record, and we can find it listed on the fax. As mentioned earlier, if we received the request by phone, we enter a placeholder such as 1234.

[Advance for animation] The system generates the Reference Number.

Directly underneath this field, we may also see a field for Genesis ID, which is only applicable if the request came through a Genesis file. This field is optional.

[Advance for animation] Next, we enter the correct Request Profile. Request profiles determine how the rest of the form populates and expected services. We enter a shortcut code to populate the correct profile. If we are unsure of the profile name, we can select the magnifying glass icon to open the Request Profile Search.

[Advance for animation] Once we select the request profile, the system automatically fills in Event Classification and Case Type. Additionally, the Eligibility Verified select box [Advance for animation] auto-completes through the system, so there is no need to attempt to select or de-select it.

[Advance for animation] We then manually enter the Reason for Referral and the Diagnosis Code. We must complete these fields as precisely as possible since they directly affect how the system and clinical reviewers process the request. Always ensure accuracy in these fields.

[Advance slide]

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Creating a New Authorization in CareRadius (5 of 8)

1. General Information tab (cont’d)

Requesting and Servicing Provider

Name, city, or National Provider Identifier (NPI)

Provider Directory
Non-Network Directory

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[Script:] After entering the general request information, the next step is to assign the Requesting Provider and Servicing Provider, which of course must match what is on the referral and authorization form. [Advance for animation]

We search for the provider using their name or National Provider Identifier (NPI).

If the provider does not appear in the search results, we can select the three-dot menu [Advance for animation] to open the Provider Directory. Within the directory, we will run a full search. In situations where the search continues to not populate the correct provider, we enter the provider manually using a generic code, which our demonstration includes. This opens the Provider Snapshot screen [Advance for animation], where we will enter key information.

For providers who are out of network, we use the Non-Network Directory, which we will view later. This process is like the standard provider search and serves as a fallback.

[Advance slide]

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Creating a New Authorization in CareRadius (6 of 8)

2. Services tab

Auto-populated fields
Facility for inpatient requests

Search and Soundex

Status and Reason

Pended and Auto-processing

56

Service Main for Inpatient Details

Admission Date and Code

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] Once we enter the provider, we move from the General Information tab to the [Advance for animation] Services tab. Many of the fields in this tab will auto-populate based on the information we entered in the General Information tab.

For inpatient admissions, as we mentioned earlier, we must enter a facility [Advance for animation].

After selecting Search, a list of facilities will appear. If more than one facility has the same address, we select the first one on the list.

Once we enter the facility, the [Advance for animation] Service Main Inpatient Details section is where we enter the actual admission date and the code from the referral/authorization form. Once we enter the admission date, the system automatically generates the authorization window starting from that date. With these fields completed, we can proceed to save the service information.

Before finalizing the request, we [Advance for animation] leave the Status as Pended and set the Reason to Auto-processing. This setting allows the system to handle the request.

[Advance slide]

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Creating a New Authorization in CareRadius (7 of 8)

3. Documentation tab

New Document Type

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Documentation must be saved under the specific Authorization tab

Authorization tab

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] Next, we go to the [Advance for animation]

Documentation tab to attach all supporting documentation by selecting the New Document Type dropdown. This may include clinical notes, medical necessity letters, or referral forms. It is important that we attach these documents under the specific [Advance for animation]

Authorization tab to ensure traceability and compliance with documentation standards. For all documents attached to the authorization, including any that come through DOMA, always double-check the beneficiary, service, provider, date of birth, gender, date, urgency, and any other defining factors for what is on file.

To add internal notes, use the [Advance for animation] Note option. Notes are visible to reviewers and should include clarifying information such as prior contact, the urgency of the situation, or any special handling instructions. Keep notes clear, concise, and professional; only including what’s necessary for understanding the request.

Of course, before submitting, we recommend always reviewing the plan and eligibility information within the Details tab or Member Information section.

Once we’ve completed all required fields, attached documentation, and verified the information, we [Advance for animation] select Save and Close.

[Advance slide]

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Creating a New Authorization in CareRadius (8 of 8)

Select Refresh to ensure the new authorization appears in the list.

Submit or Save as Draft
Reference Number
Status Monitoring: Activity tab → Authorizations

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Demonstration Two: Creating an Authorization

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Activity Two: Creating an Authorization

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Time for completion: 25 minutes

When finished: Emoji in the chat

Participant Guide: Appendix A, Activity Two

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] We will now begin our next activity, which is to create an authorization.

In your Participant Guide, select the activity link and follow the steps to complete your activity.

[Producer re-adds the Participant Guide link to the chat, stating: “We will now begin Activity Two: Creating an Authorization, which you will find steps for in Appendix A of your Participant Guide.”]

We’ll start our timer for 25 minutes, which gives us plenty of time to complete the activity. If you encounter blockers along the way or have questions that pertain to the activity, use the chat to communicate those, and we’ll assist you.

If you complete the activity before the time is up, we ask that you put an emoji of your choice in the chat.

Are there any questions before we start the timer? [Pause for discussion] Okay, you may begin.

[Facilitator begins the built-in Microsoft Teams Timer and monitors the chat for questions.]

Great job with completing Activity Two! Now, we’re going to complete two knowledge checks.

[End of Activity - Advance slide]

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Knowledge Check 7

Enter your answer into the chat.

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Which of these essential fields come from the referral/authorization form?

Select three correct responses.

A

Reference Number

B

Contact Name and Phone

C

Reason for Referral

D

Diagnosis Code

?

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Knowledge Check 8

Enter your answer into the chat.

Proprietary and Confidential

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In which tab do you select the New button to create a new authorization in CareRadius?

A

Details tab

B

Activity tab

C

Documentation tab

D

General Information tab

?

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Section Six:�Prospective Review Scenarios

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Prospective Review Scenario One

Jorge Aguilar is a 58-year-old Prime Retired beneficiary who has been diagnosed with unilateral primary osteoarthritis on his right knee. The MTF sent a request for HH PPS services. Per Genesis note: "Please begin Home Physical Therapy 3 times per week for 2 weeks using the WBAMC Total knee protocol. Start care 2 Feb 26.”

Steps

Retrieve the referral/authorization form from DOMA.
Export the DOMA fax to CareRadius.
Create the CareRadius authorization.
Use the Referral Codes and Profile Review Resource to check that you use the correct request profile code based on the CPT/HCPCS code.

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[Script:] Here is the first scenario: Jorge Aguilar is a 58-year-old Prime Retired beneficiary who has been diagnosed with unilateral primary osteoarthritis on his right knee. The MTF sent a request for HH PPS services. Per Genesis note: "Please begin Home Physical Therapy 3 times per week for 2 weeks using the WBAMC Total knee protocol. Start care 2 Feb 26.”

Here are the steps that you would perform while doing your job. First, you would retrieve the referral and authorization form from DOMA. Then, you would export the DOMA fax to CareRadius. Then, you would create the CareRadius authorization and use the Referral Codes and Profile Review Resource to check that you use the correct request profile code based on the CPT/HCPCS code.

Because we don’t have access to training environments for DOMA and DIA, we will skip steps one and two for the training and start with step three. This means that you will create the authorization in CareRadius and use the Referral Codes and Profile Review Resource to check that you use the correct request profile code based on the CPT/HCPCS code.

[Advance slide]

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Activity Three: Prospective Review Scenario One

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Time for completion: 25 minutes

When finished: Emoji in the chat

Participant Guide: Appendix A, Activity Three

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] We will now begin our next activity, which is to build the authorization for scenario one. In a moment, the producer will put the referral/authorization form that you would get from DOMA into the chat so that you can build it.

In your Participant Guide, select the activity link and follow the steps to complete your activity.

[Producer re-adds the Participant Guide link to the chat, stating: “We will now begin Activity Three: Prospective Review Scenario One, which you will find steps for in Appendix A of your Participant Guide.”]

We’ll start our timer for 25 minutes, which gives us plenty of time to complete the activity. If you encounter blockers along the way or have questions that pertain to the activity, use the chat to communicate those, and we’ll assist you.

If you complete the activity before the time is up, we ask that you put an emoji of your choice in the chat.

Are there any questions before we start the timer? [Pause for discussion] Okay, you may begin.

[Facilitator begins the built-in Microsoft Teams Timer and monitors the chat for questions.]

[End of Activity - Advance slide]

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Prospective Review Scenario Two

Rosemary Hansen is a 26-year-old Prime active duty family member. She has been diagnosed with hypertrophy of breast and stated macromastia. As a result, she suffers from anterior chest, back, neck and shoulder pain. The request is for breast reduction surgery.

Steps

Retrieve the referral/authorization form from DOMA.
Export the DOMA fax to CareRadius.
Create the CareRadius authorization.
Use the Referral Codes and Profile Review Resource to check that you use the correct request profile code based on the CPT/HCPCS code.

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Activity Four: Prospective Review Scenario Two

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Time for completion: 25 minutes

When finished: Emoji in the chat

Participant Guide: Appendix A, Activity Four

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] We will now begin our next activity, which is to build the authorization for scenario two. In a moment, the producer will put the referral and authorization form that you would get from DOMA into the chat so that you can build it.

In your Participant Guide, select the activity link and follow the steps to complete your activity.

[Producer re-adds the Participant Guide link to the chat, stating: “We will now begin Activity Four: Prospective Review Scenario Two, which you will find steps for in Appendix A of your Participant Guide.”]

We’ll start our timer for 25 minutes, which gives us plenty of time to complete the activity. If you encounter blockers along the way or have questions that pertain to the activity, use the chat to communicate those, and we’ll assist you.

If you complete the activity before the time is up, we ask that you put an emoji of your choice in the chat.

Are there any questions before we start the timer? [Pause for discussion] Okay, you may begin.

[Facilitator begins the built-in Microsoft Teams Timer and monitors the chat for questions.]

[End of Activity - Advance slide]

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Prospective Review Scenario Three

Tim Wu is a 21-year-old Prime active duty service member who has become deconditioned from pneumonia. You receive a request for admission to a skilled nursing facility.

Steps

Retrieve the referral/authorization form from DOMA.
Export the DOMA fax to CareRadius.
Create the CareRadius authorization.
Use the Referral Codes and Profile Review Resource to check that you use the correct request profile code based on the CPT/HCPCS code.

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Activity Five: Prospective Review Scenario Three

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Time for completion: 25 minutes

When finished: Emoji in the chat

Participant Guide: Appendix A, Activity Five

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] We will now begin our next activity, which is to build the authorization for scenario three. In a moment, the producer will put the referral and authorization form that you would get from DOMA into the chat so that you can build it.

In your Participant Guide, select the activity link and follow the steps to complete your activity.

[Producer re-adds the Participant Guide link to the chat, stating: “We will now begin Activity Five: Prospective Review Scenario Three, which you will find steps for in Appendix A of your Participant Guide.”]

We’ll start our timer for 25 minutes, which gives us plenty of time to complete the activity. If you encounter blockers along the way or have questions that pertain to the activity, use the chat to communicate those, and we’ll assist you.

If you complete the activity before the time is up, we ask that you put an emoji of your choice in the chat.

Are there any questions before we start the timer? [Pause for discussion] Okay, you may begin.

[Facilitator begins the built-in Microsoft Teams Timer and monitors the chat for questions.]

[End of Activity - Advance slide]

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Wrap Up

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Questions & Answers

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What questions do you have?

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Mastery Check & Learner Satisfaction Questionnaire

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T-5: Specialist Role and Systems Training – Prospective Review

UM Specialist Role and Systems Training – Prospective Review | Version 1.0

[Script:] Thank you for your time and engagement today. To receive credit for attending today’s session, you will complete a 10-question Mastery Check, located in the learning management system. Sign into the learning management system, and then scroll to the My Training section of the Home page.

[Advance for animation]

Locate the course in the Not Started tab. Then, select the course titled: [Advance for animation]

T-5: Specialist Role and Systems Training – Prospective Review.

If the course does not display for you,

[Advance for animation]

select the See All Assigned Courses & Learning Paths button to view a full list of assigned training.

[Producer pastes link to the LMS in chat]

Complete the 10-question Mastery Check and the Learner Satisfaction Questionnaire to provide us with valuable feedback. Both items should take less than 20 minutes to complete.

[Advance slide]

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Thank you!

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