Preauthorization help
Don't see your question listed here? Let us know and we'll work on adding it to our list!
Eligibility
Preauthorization tool
System requirements, access and security
Downloading files
Code look-up
Eligibility
Question:
Do I have to check eligibility prior to submitting a request for service?
Answer:
The Preauthorization tool has been designed to verify eligibility once the Member ID # and the initial date of service are entered. However, enrollment transactions may occur retroactively. Eligibility responses are not a guarantee of payment or authorization of services.
| Back to top |
Question:
I first verified that my patient was eligible using the Preauthorization tool, and my preauthorization was approved but my claim was rejected as "Reject not eligible." How accurate is the information that Provider Tools uses?
Answer:
When verifying eligibility, Provider Tools uses the most current information at the time of your request. However, enrollment transactions may occur retroactively. Eligibility responses are not a guarantee of payment or authorization of services.
| Back to top |
Question:
When using the Preauthorization tool, I received an eligibility response of "Member Not Found." What does this mean?
Answer:
The response “Member Not Found” may indicate one or more issues. For example, the provider using the tool may not have access to this member, the member may have terminated, the member may not be an actual FCHP member, the PCP needs correction, or the wrong Member ID # may have been entered. Please re-check your information and attempt to enter again. If you continue to have this problem, please contact FCHP Customer Service or fax directly to Care Review at 1-508-368-9700.
| Back to top |
Question:
When I received my patient's eligibility results, "Contact Customer Service" appeared in place of a PCP name. What does this mean?
Answer:
If FCHP does not have a PCP on record for the member you're searching for, "Contact Customer Service" will be displayed as the PCP name and "1-866-ASK-FCHP, press 2" will be displayed as the PCP phone number in your search results. Please inform the member that they should contact FCHP Customer Service at 1-800-868-5200 to update their member information.
| Back to top |
Question:
When verifying my patient's eligibility, I noticed that my phone number is incorrect. How can I update my information?
Answer:
Please call 1-866-ASK-FCHP and press 4, or send an e-mail.
| Back to top |
Preauthorization tool
Question:
What is a service type?
Answer:
A service type is a high-level description of the service to be requested. There are four service types: Outpatient/SDS, Inpatient, DME and Transportation.
Use Outpatient/SDS for all authorization requests for procedures done in the office or hospital outpatient setting. Remember, not all procedures require preauthorization. Use FCHP’s Procedure code look-up to determine if your request requires authorization.
| Back to top |
Question:
What is a service type code?
Answer:
Service type codes are HIPAA X12 defined codes, and offer a more detailed description of the service type. Example: If you need to request a service for same-day surgery, then the service type would be Outpatient/SDS, and the service type code would be Hospital-Ambulatory Surgical.
| Back to top |
Question:
Is service type provider-specific?
Answer:
Yes, service types are specific to whether you are a PCP, specialist, facility or DME provider.
| Back to top |
Question:
How do I submit a request for a patient to see a specialist?
Answer:
You no longer need to submit a referral for specialty visits within the member's network.
Learn more about our improved referral process
| Back to top |
Question:
Which service type and service type code do I select to request pain clinic services?
Answer:
For pain clinic services, please request service type of Referral and service type code (HIPAA X12) of Anesthesia.
| Back to top |
Question:
Can a request to a non-contracted provider be made through the Preauthorization tool?
Answer:
No, the Preauthorization tool is specifically designed to be used by and for FCHP-contracted providers.
| Back to top |
Question:
Do all service types require diagnosis codes?
Answer:
Yes, all service types require a diagnosis code. This will assist in the review process if necessary.
| Back to top |
Question:
Do all service types require procedure codes?
Answer:
Yes, procedure codes are required for specific services other than Referral service type and must be indicated on the form for those required service type codes.
| Back to top |
Question:
How do I know what procedures require preauthorization?
Answer:
For office- or facility-based procedures, FCHP has a designated list of procedure codes that require plan preauthorization. For procedures not on the list, no additional preauthorization or notification is required unless the service is being performed or provided at tertiary or non-contracted facilities. Use FCHP’s Procedure code look-up to determine if your request requires authorization.
| Back to top |
Question:
How do I know which durable medical equipment (DME) services require preauthorization and/or a certificate of medical necessity (CMN)?
Answer:
FCHP does not require preauthorization on all DME services. Use FCHP’s Procedure code look-up to determine if your request requires authorization.
| Back to top |
Question:
Can a request for service be modified?
Answer:
Yes, requests for service can be modified on designated fields relating to the specific service type code. For example, you may request additional visits or alter the expected date of service to a future date. Specific requests, such as those for durable medical equipment (DME), may not be modified online. If you have a question about any request that you are unable to modify through Provider Tools, you may call Care Review at 1-866-ASK-FCHP, and press 3 for assistance.
| Back to top |
Question:
What number do I call if I have questions regarding my request?
Answer:
You should contact FCHP at 1-866-ASK-FCHP, and press 3 to speak with a Care Review representative regarding questions on requests for service.
| Back to top |
Question:
How do I check the status of my request for service?
Answer:
You may check the status of a request by clicking on the View status & report section of the Preauthorization tool. You simply select the service date, and any one or more combinations of search criteria. The Member ID # or Referral # are two examples of the search criteria.
| Back to top |
Question:
Can I print out my request for service?
Answer:
Once you have confirmed your request, you have the ability to choose a print-friendly page for your records.
| Back to top |
System requirements, access and security
Question:
What are the system requirements to use Provider Tools?
Answer:
The requirements to use the various Provider Tools, including electronic submission are:
- an Internet connection (56K modem or high-speed connection)
- a Web browser (We recommend Internet Explorer 5.x or higher.)
- a username and password supplied by FCHP
Download a current version of Internet Explorer.
| Back to top |
Question:
What if I need help using Fallon Community Health Plan's (FCHP) Provider Tools?
Answer:
FCHP will be happy to assist you. Please contact our EDI coordinators at 1-866-ASK-FCHP, extension 69968, or via e-mail.
| Back to top |
Question:
How can I give access to new employees and remove access for employees who no longer work for me?
Answer:
To obtain access for new employees, please complete a Provider Tools and Electronic Data Submission Enrollment Form and send to:
Fallon Community Health Plan
Attn: EDI Coordinators
10 Chestnut St.
Worcester, MA 01608-2810
Please notify FCHP immediately at 1-866-ASK-FCHP, extension 69968, to disable access for employees who have terminated employment. Also, if you feel the security of a password has been compromised, please notify FCHP immediately.
| Back to top |
Question:
How can I be sure the information is secure going over the Internet?
Answer:
This site uses 128-bit Secure Sockets Layer (SSL) encryption, the highest level of encryption currently available. Once you are logged into the FCHP site, all information transferred is sent using SSL. When you are accessing pages on www.fchp.org, there is a lock icon located on the bottom right of your browser window.
| Back to top |
Question:
Can another FCHP-contracted provider view my preauthorization information?
Answer:
No, FCHP limits access to claims information by your provider identification number. FCHP is committed to keeping information secure and confidential.
| Back to top |
Downloading files
Question:
How do I download preauthorization information?
Answer:
One-click reports are always in the format of a download. When running search criteria, you are given the option to "View results on-screen" or "Download to file." Choose "Download to file." Your data will be transmitted in a comma separated, or ".csv," format. Click “Continue” from the claims download page. Note that the approximate size and time to download will display based on your Internet connection. Next, a file download box will appear, and you have the option to open the file or save the file to your computer. Open the data using a spreadsheet application (such as Microsoft Excel), and you then may sort the data in any way that you choose.
| Back to top |
Question:
I am successful at downloading files, but it takes a lot of time. Is there a faster way?
Answer:
How fast your file downloads depends on the size of the file and your Internet connection method. Broadband connection via cable or DSL will result in much faster downloads than a 56K modem connection.
You may also limit your search criteria by selecting more specific information.
| Back to top |
Code look-up
Question:
Why did I not receive any results when I was searching for a procedure or diagnosis code?
Answer:
The Procedure code look-up contains active CPT and HCPCS codes. The code you are searching for may no longer be in use per CPT.
The Diagnosis code look-up contains only active and complete ICD-9-CM codes. If you are searching for an incomplete diagnosis code, you will receive a message that 0 results were found. FCHP requires coding to the highest specificity and therefore contains only the complete codes. The Diagnosis code look-up is only accessed when entering an Online referrals request.
| Back to top |
Question:
How do I search by description using the code look-up?
Answer:
First, select to search by description. You may choose “beginning of phrase” or “anywhere in phrase.”
Example 1: You may want to search for anesthesia codes. To do this, you would select “beginning of phrase” and enter “anesthesia”. The results return all codes beginning with the word anesthesia—the codes relating to the administration of anesthesia.
Example 2: You may want to search for evaluation and management codes. Select “anywhere in phrase” and enter “evaluation and management”. The results return all codes where evaluation and management is in the description, sorted by code.
| Back to top |