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	Frequently Asked Questions

Prior Authorization-FAQ's

Q6. Since the hospital is the responsible party and this new service requires additional resources and planning, will HFS allow a grace or transitional period?

Q7. Does HFS want Prior Authorizations on back surgeries for all primary, secondary, or third party Medicaid payers?

Q8. What if Medicaid eligibility is not established prior to admission for a procedure on HFS Attachment F?

Q9. Will concurrent review be performed for Prior Authorization requests?

Q10. If the patient is in inpatient status at a hospital (i.e. admitted with angina or severe back pain); then condition persists to where CABG or Back Surgery is scheduled a few days later, does this require Prior Authorization?

Q11. If a patient is admitted with chest pain and discharged, then a CABG is scheduled in two weeks does this require Prior Authorization?

Q12. If a patient comes into the emergency room and suddenly needs one of the elective surgeries, how can it be pre-authorized by a physician if they didn't know the patient needed it?

Q13. If the primary dx code submitted for Prior Authorization review changes, do we need to contact eQHealth to change it on the review?

Q14. If an admission has an admitting dx code that is on Attachment C (reviewable) and there is a prior authorization on file for an ICD9 procedure on Attachment F, will the case require both prior authorization and concurrent review?

Q15. If a Prior Authorization is denied, can a new review be initiated?

Q16. What criteria are used to determine the medical necessity of the procedure?

Q17. Who can hospitals contact for questions regarding billing or payment?

Q18. Have all Medicaid physicians been notified of this new service?

Q19. Will the physician/surgeon be penalized if the case gets denied?

Q20. If a review is referred to an eQHealth Physician Reviewer, does peer-to-peer contact occur?

Q21. If a review is referred to a 2nd level Physician Reviewer (reconsideration), and a determination is rendered, will the hospital and surgeon be notified?

Q22. What do hospitals do if the physician does not have a physician ID number from HFS?

Q23. If the Prior Authorization is referred for physician review, can the eQHealth Physician speak with a registered nurse or a physician assistant instead of the surgeon?

Q24. Why can’t the surgeon’s office initiate the review request? Can the hospital grant a user name and password to the physician office and have them submit the request?

Q25. Who is my eQHealth liaison?

Q26. Is it the responsibility of the liaison to submit a review request?

Q27. Can a hospital have an additional eQSuite Web Administrator for assignment of users for Prior Authorization?

Q28. Will the eQHealth Liaison still receive all review notifications from eQHealth?

Q29. Why is the hospital responsible for submitting a Prior Authorization review request when they do not have the clinical information needed for the review?

Frequently Asked Questions-Prior Authorization Review

To download a pdf file or print the Frequently Asked Questions, click here.

KEPRO
500 Waters Edge, Suite 125
Lombard, IL 60148
Business Phone: (630) 317-5100
Provider Helpline: 800-418-4045
Business Fax:800.418.4039

Review Certification Line: 800.418.4033 - Mon-Fri, 8:30 am to 5:00 pm, CST
Provider Helpline: Submit your questions online through eQSuite®, Monday - Friday 8:30 am to 5 pm, CST. Critical access and out-of-state hospitals please call 800.418.4045 for assistance.
Fax line (addtl info or reconsideration requests): 800-418-4039