Skip Ribbon Commands Skip to main content




Lists
BTCare Help
New Authorization

Authorization Types
There are 13 authorization/referral types. They appear in the drop-down list that displays when you select NEW AUTHORIZATION from the AUTHORIZATIONS / REFERRALS menu.


Ambulance Services


Diagnostic Testing

To request diagnostic imaging and lab services requiring prior authorization -- such as Bone Density Studies, Genetic Testing, Heart Scans, Infertility Testing, PET Scans, and MRIs -- as well as testing by out-of-network providers



DME/Orthotics/Prosthetics

To request Durable Medical Equipment (codes A4000-A8999, E0100-E999, and Sculptra), Orthotics (codes L0000-L4999) and Prosthetics (codes L5000-L9999).



Drugs Requiring Authorization

To request medications on the Prior Authorization List, such as self-injectables, chemotherapy adjunctive treatment, office-based infusions and hospital-based infusions.



Home Care Services

To request home services on the Prior Authorization List, such as skilled nursing, home-based PT and home infusion.



Hospital Admission

To request hospital admission for surgeries, Total OB Care, transplants and other pre-scheduled services. BTMG uses this authorization type for emergency admissions, as well as Skilled Nursing Facility and Acute Rehabilitation admissions.



Infertility

To request office-based infertility services. For infertility-related drugs, use Drugs Requiring Authorization. For hospital-based testing, use Diagnostic Testing.



Outpatient Rehab

To request outpatient therapy services such as acupuncture, chiropractic treatment, biofeedback, cardiac rehabilitation, occupational therapy, and speech therapy.



Outpatient/Office Services

To request surgical procedures done at hospital outpatient surgery areas and ambulatory surgery centers, such as GI endoscopic procedures and colonoscopies.



Outpatient Surgery

To request office-based procedures on the Prior Authorization List, such as neuropsychological testing, pain management, cosmetic procedures, blood transfusions and dialysis.



Specialist Referral

To request referrals to in-network or out-of-network specialists. Do NOT use this authorization type for child development, infertility and pain management services.



Transplant Outpatient

To request transplant-related outpatient services. For inpatient transplant procedures, use Hospital Admission.



Vaccines Requiring Authorization

To request vaccines on the Prior Authorization List, such as travel immunizations, and Hepatitis A and B vaccines for patients over the age of 18.

Each type of authorization has its own form. The forms consist of common fields, which are the same for every type, and specialized fields, which vary for different types.

Authorization Form - Common Fields
These fields appear on every authorization form.

Date Ordered

The date on which the authorization is being requested. Defaults to today's date. This field does not accept future dates.

Insurance
The Health Care Plan that will be charged for the services. Defaults to the patient's Primary Insurance as of the DATE ORDERED. Click the ellipsis button [...] to view a list of the patient's current and expired contracts as of the Date Ordered.

Member #
Defaults to the ID number for the Health Care Plan specified in the INSURANCE field. This field is read-only.

Status
Defaults to Pending. This field is read-only.

Priority
The priority of the request. These are the options: Urgent, Routine, Concurrent, and Retro. The default is Routine.

Requesting Provider
The name of the physician requesting the authorization. Typing the first few characters of the physician's last name and clicking the ellipsis button [...] displays a Lookup dialog box.

Contact Name
The person at the requesting provider's office to whom questions should be directed. This is a free-text field.

Contact Number
The phone number of the contact person at the requesting provider's office. This is a free-text field.

Valid From Date
The date on which the authorization becomes effective.

Valid To Date
The date on which the authorization expires.

Diagnosis 1
The ICD-9 code and description of the patient's primary diagnosis. Typing the first two characters of the code or the description and clicking the ellipsis button [...] displays a Lookup dialog box.

Diagnosis 2
The ICD-9 code and description of the patient's secondary diagnosis. See Diagnosis 1.

Diagnosis 3
The ICD-9 code and description of the patient's tertiary diagnosis. See Diagnosis 1.

Requested Procedure(s): For additional fields, click the Add Procedure button.

Code
The CPT code for the procedure. Typing the first few characters of the code or the description and clicking the ellipsis button [...] displays a Lookup dialog box.

Description
A brief description of the procedure.

Modifier
The modifier for the procedure code. Clicking the ellipsis button [...] displays a Lookup dialog box.

Units
The number of times the procedure will be performed.

Additional Clinical Information for Medical Review
Free text comment area for information such as history, diagnostic test/lab results, current medications.


Authorization Form - Specialized Fields
These fields are different for every Authorization Type. For example, here are the fields that appear on a Hospital Admission request:

Hospital
The hospital where the patient will be admitted.

In Network

Indicates whether the hospital is contracted to BTMG.

Type of Admit

For example, Intensive Care, Maternity, etc.

Planned/Expected Admission Date
The scheduled admission date or EDC.

Attending Physician
The name of the doctor who has primary responsibility for the patient's treatment.

Assistant Surgeon Required?
Yes/No. A message will display if an assistant surgeon is not allowed for the requested procedures.

Assistant Surgeon
The name of the surgeon who will assist the operating surgeon in the performance of the surgical procedure. This field is required if you selected Yes in the previous field. A message will display if the assistant surgeon is out-of-network.

Co-Surgeon
The name of a co-surgeon, if one is necessary due to the nature of the procedure(s) or the patient's condition.


Specialist Referral Form
This form is used to request both in-network and out-of-network specialist referrals.

Date Ordered

The date on which the referral is being requested. Defaults to today's date. This field does not accept future dates.

Insurance
The Health Plan that will be charged for the services. Defaults to the patient's Primary Insurance as of the Date Ordered. Click the ellipsis button [...] to view a list of the patient?s current and expired contracts as of the Date Ordered.

Member #
Defaults to the ID number for the Health Care Plan specified in the Insurance field. This field is read-only.

Status
Defaults to Pending. This field is read-only.

Priority
The priority of the request. These are the options: Urgent, Routine, Concurrent, and Retro. The default is Routine.

Requesting Provider
The name of the physician requesting the authorization. Typing the first few characters of the physician?s last name and clicking the ellipsis button [...] displays a Lookup dialog box.

Contact Name
The person at the requesting provider's office to whom questions should be directed. This is a free-text field.

Contact Number
The phone number of the contact person at the requesting provider's office. This is a free-text field.

Valid From Date

The effective date of the referral. By default, referrals are valid for 6 months.

Valid To Date
The expiration date of the referral.

Diagnosis 1
The ICD-9 code and description of the patient?s primary diagnosis. Typing the first two characters of the code or the description and clicking the ellipsis button [...] displays a Lookup dialog box.

Note:
If you enter a CVA code (434.91) in a DIAGNOSIS field, the Case Management Referral Form will display in a dialog box.

If you enter a CHF, Diabetes, Asthma/COPD, HIV, MI or CIHD code in a DIAGNOSIS field, the Disease Management Referral Form will display in a dialog box.


Diagnosis 2
The ICD-9 code and description of the patient's secondary diagnosis. See Diagnosis 1.

Diagnosis 3
The ICD-9 code and description of the patient's tertiary diagnosis. See Diagnosis 1.

Referred to Specialist
The specialist's name. Typing the first few letters of the specialist's last name and clicking the ellipsis button [...] displays a Lookup dialog box.

Note:
If the patient is a CalPERS member and the specialist is not contracted to provide services at CalPERS network hospitals, a dialog box will display when you click the SAVE button, giving you the option to cancel the request.


Specialty
A drop-down list of medical specialties. If Allergy, Otolaryngology, or Dermatology is selected, a series of questions will display when you click the SAVE button. For example:

Has the patient been evaluated by you for this condition within the last six weeks?
Has treatment failed?


Respond to the questions with Y or N.

In Network
Drop-down list: Yes or No. Indicates whether the REFERRED TO SPECIALIST is contracted to BTMG.

Address
The specialist's address. Filled in automatically for in-network specialists.

Phone Number
The specialist's phone number. Filled in automatically for in-network specialists.

Fax Number
The specialist's fax number. Filled in automatically for in-network specialists.

Services Requested
Drop-down list: Consult only, Evaluate and treat, Chronic disease management, Second opinion.

Patient Requested Referral?
Drop-down list: Yes and No.

Date of last visit to PCP for this condition
This date field accepts most numeric formats; however, only a past date may be entered. There is also a Calendar selector.

Clinical Information for Specialist:

Additional Clinical Information for medical review, such as history, diagnostic test results, current medications.
A summary of the patient's symptoms and medical history. This is a free-text field.
Current Medication List
The medications the patient is currently taking. This is a free-text field.
Pertinent lab/x-ray results
A summary of relevant lab and x-ray results for the patient. This is a free-text field.