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Referrals and Auths

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  • Which two tools do we use to check on someone's authorization?
    Salesforce First, CareRadius Second
  • Scenario: An ADSM does not get a referral, do they have to pay for that appointment out of pocket?
    Yes
  • Which health plans do not require a referral?
    Tricare Select and all other PPo type plans
  • How long is an EOC timeframe for am ADSM?
    6 months
  • What is Continuity of Care?
    allowing the patient to have an ongoing relationship with their provider despite changes
  • How do TRICARE referrals and authorizations work with OHI?
    Must follow the rules of the OHI first then filter down to TRICARE
  • Which health Plans Require a Referral?
    Tricare Prime, TPR, TPRO, TPO
  • What type of training does Line Of Duty apply to?
    Active Duty Training, Inactive Duty Training, Drill Weekend, Any other training while on 30 days or less orders
  • How long is an EOC timeframe for anyone Other than an ADSM?
    365 days
  • Scenerio: An ADFM does not get a referral, do they have to pay for that appointment out of pocket?
    Point Of Service
  • Which tool do we use to determine if something requires an Authorization?
    RADS
  • Does an ADSM require an Authorization for Urgent care?
    yes. They have the Nurse Advice line or the emergency room if it is 'urgent', otherwise they must wait for auth.
  • Which Article in the Knowledge Base goes over helping providers with an auth/referral in Availity?
    1327
  • Which Article in Knowledge base goes over LOD Claim inquiries?
    1236
  • What two factors contribute to how long a referral lasts?
    EOC Timeframe and Visit count
  • Which FAQ document helps with the path to walk a bene to a referral or auth in their Bene portal?
    1092
  • Who handles LOD and some Tricare Prime Remote claims or auths?
    DHA-GL (Defense Health Agency - Great Lakes)
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