Authorization Dashboard
Real-time authorization intelligence
Requirements
- Clinical notes ≥ 3 months
- Prior auth for all surgical
- AIM specialty solutions portal
- ICD-10 specificity required
- Functional assessments for MSK
Common Denials
- Medical necessity not met (42%)
- Missing imaging reports
- Conservative tx not documented
- Provider not in network
- Eligibility mismatch on submission
Success Strategies
- Document all conservative treatments
- Include functional outcome measures
- Direct physician P2P preferred
- Cite UHC coverage policy number
- Appeal within 60 days
Requirements
- eviCore portal for MSK
- 6-week conservative trial
- MRI within 6 months for spine
- Clinical Reviewer criteria strict
- Surgery criteria per clinical guidelines
Common Denials
- Incomplete clinical documentation
- Conservative tx insufficient
- Alternative tx not explored
- Out of date imaging
- Coding errors on submission
Success Strategies
- Detailed narrative letter
- Include PT notes
- Request expedited review for STAT
- P2P with Aetna MD reviewer
- Escalate to internal appeals fast
Requirements
- Carecore/Cohere portal
- 8-week PT trial for spine/MSK
- Functional capacity assessment
- Prior imaging and diagnosis
- Written clinical justification
Common Denials
- Medical necessity (38%)
- Experimental procedure flag
- Documentation gap
- Non-preferred provider
- Coverage limitation applies
Success Strategies
- Clinical pathways letter template
- PROMIS scores improve success
- Same-day P2P callback protocol
- Level II appeal with peer review
- Pre-auth before scheduling
Requirements
- AIM specialty solutions
- Blue Distinction program factors
- Conservative tx 4-6 weeks
- Clinical criteria per BCBS policy
- Member eligibility verified
Common Denials
- Criteria not established
- Missing conservative tx timeline
- Imaging not current
- Inconsistent ICD-10 codes
- Authorization not obtained prior
Success Strategies
- Blue Distinction Center advantage
- Strong documentation timeline
- P2P with clinical reviewers
- Reference BCBS medical policy
- Timely resubmission
Requirements
- Prior auth via Availity
- Clinical notes last 30-90 days
- Conservative tx documentation
- Physician attestation letter
- CPT/diagnosis alignment
Common Denials
- Medical necessity (35%)
- Documentation missing
- Member benefit limit reached
- Incorrect provider info
- Procedure not covered
Success Strategies
- Include outcome measures
- Written P2P request first
- Copy clinical guidelines in appeal
- Use Humana appeal form
- Expedite with MD signature
Requirements
- LCD/NCD compliance mandatory
- ABN when coverage uncertain
- Prior auth for 278 service types
- Medical necessity documented
- Beneficiary eligibility check
Common Denials
- LCD criteria not met (45%)
- Missing supporting diagnosis
- Service frequency exceeded
- Duplicate claim submitted
- ABN not obtained
Success Strategies
- Reference specific LCD number
- Include all supporting ICD-10s
- File detailed appeal with ALJ
- Keep ABN on file
- Redetermination within 120 days
| Staff | Cases | Approval% | Avg Days |
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| Patient | Practice | Payer | Procedure | Status | SMART | SLA | Risk | Assigned | P2P |
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P2P Command Center
Peer-to-peer coordination, escalation tracking & outcome management
| Urgency | Patient / Practice | Payer | Physician | Specialist | Scheduled | Call Status | Financial Impact | Overturn |
|---|---|---|---|---|---|---|---|---|
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| Patient | Practice | Payer | Procedure | Denial Reason | Days Waiting | Revenue | Assigned |
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| Payer | Total Attempts | Overturned | Overturn Rate |
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Opening Statement
"Good morning, this is [Name] from [Practice] calling for a peer-to-peer review regarding authorization reference #[REF]. I'm requesting to speak with the reviewing physician regarding the denial of [Procedure] for [Patient]."
Key Clinical Arguments
1. Patient has failed 3+ months of conservative treatment including PT and medication management.
2. Imaging confirms diagnosis meeting UHC Clinical Guidelines CP.MP.234.
3. Functional impairment documented: VAS pain score 8/10, limited ADLs.
Opening
"Hello, I'm calling from [Practice] for a peer-to-peer discussion on auth denial for [Patient]. I'd like to discuss the clinical evidence supporting medical necessity."
Key Points
Document 6-week PT trial. Reference Aetna CPB number. Conservative management exhausted: medications, injections, therapy all failed. Imaging current within 6 months.
Opening
"This is [Name] calling from [Practice] for a peer-to-peer regarding denial auth #[REF]. We believe this meets Cigna's medical necessity criteria and have clinical documentation to support."
Key Points
Reference Cigna MCG criteria. Document PROMIS-29 outcomes. Highlight 8-week PT non-response. Cite specialist recommendation letter.
Opening
"Hello, I'm calling for a peer-to-peer review for auth denial for [Patient]. We'd like to discuss the medical necessity and present additional clinical evidence."
Key Points
Reference BCBS Medical Policy number. Document conservative treatment timeline. Include functional assessment scores. Blue Distinction Center quality metrics.
Opening
"Good afternoon, I'm [Name] from [Practice], calling to request a physician-to-physician review for Humana authorization. We have clinical justification to support medical necessity."
Key Points
Use Humana Clinical Criteria. Document failed conservative tx. Include surgeon attestation letter. Functional outcome measures required.
Opening
"This is [Name] from [Practice], requesting a redetermination peer review for Medicare claim for [Patient]. The procedure meets LCD requirements and we have supporting documentation."
Key Points
Cite specific LCD article number. Include all supporting ICD-10s. Document per CMS guidelines. File within 120-day redetermination window.