IHCP reminds providers how to interpret PA status information

IHCP reminds providers how to interpret PA status information

As stated in BR201715, prior authorization (PA) status codes displayed on the Portal comply with the Health Insurance Portability and Accountability Act (HIPAA) 278 transaction standards and provide only a high-level, standardized description of the actual working status of the PA request. PA status information reported through the Interactive Voice Response (IVR) system is also only a high-level description. PA notification letters mailed to the provider and member, however, continue to provide the more detailed administrative working status that providers are accustomed to, and more clearly explain the current status of the PA request.

The following table provides a crosswalk between the standard response categories reported on the Portal and through the IVR with the administrative working statuses associated with each standard response category. Providers should use this table to help them understand the standardized HIPAA-compliant status responses when conducting a PA inquiry. The crosswalk table below will also be available on the PA Status Code page for future reference. Providers should refer to their PA notification letters for additional information regarding the more detailed working status of a PA request.

Table 1 - HIPAA-compliant PA status responses crosswalked with associated administrative working statuses

Portal/278 PA Status IVR PA Status
Administrative Working PA Status in Decision Letters PA Status Code
Certified in Total "…is approved." APPROVED - Approved
APPR THRU ADMIN REV - Approved through administrative review Y
APPR/CONTIN OF SERV - Approved for continuation of service F
AUTO APPR AFTER 10 - Automatically approved after 10 days Z
DEC OVERTURN BY ALJ - Decision overturned by administrative law judge (ALJ) C
DIS NO HEARING APPR - Appeal dismissed, no hearing, request approved S
NON-COV CODE APPROVE - Noncovered code, approved B

Modified "…is modified." DIS NO HEARING MOD - Appeal dismissed, no hearing, request modified T
MOD THRU COURT - Decision modified through court action V
MODIFIED - Modified M
MOD/CONTIN OF SERV - Modified for continuation of service G
MOD THRU ADMIN REV - Modified through administrative review X

No Action Required "…is not assigned; request does not require PA." NO PA REQUIRED - No PA required N
NO PA REQ FOR PMP - No PA required when requested by a PMP O

Not Certified "…is denied." DIS NO HEARING DEN - Appeal dismissed, no hearing, request denied U
DEC UPHELD BY ALJ - Decision upheld by ALJ W
DENIED - Denied D
DEN/CONTIN OF SERV - Denied for continuation of service H
NON-COV CODE DENIED - Noncovered code, denied I
"...is rejected." REJECTED - Rejected R

Pended "…has been suspended for further information." SUSPENDED - Suspended for further review K
"…is pending written documentation." PENDING - Pending receipt of required information P