TruCare ProAuth™ Documentation

• 0120 for Medical and Obstetric stay levels
  
  
• 0022 for Skilled Nursing Facility (SNF) or Swing Bed stay levels
  
  
• 0024 for Acute Rehab
  
  
• Primary procedure code for Elective/Surgical stay levels (enter additional codes in the Add Notes section)

• See the FAQ on “How do I check authorization requirements on more than one code?”
  
  
• Enter the primary procedure code on the first screen.
  
  
• Enter the additional codes in the Add Notes section that appears on the second screen.
  
  
• Martin’s Point staff will update your request to include the additional codes that require prior authorization.
  
  
• This is a system limitation that is a planned future enhancement for TruCare ProAuth™.

• Effective August 1, 2021 - 97151, 97153, 97155, 97156, 97157, and 97158 are the only codes TRICARE covers under the Autism Care Demonstration. 
  
  
• Prior to August 1, 2021 - 97151, 97153, 97155, 97156 and T1023 are the only codes TRICARE covers under the Autism Care Demonstration.
  
  
• Enter 6 as the units and months as the unit type.

For USFHP only - All hospice authorization requests (even if services are being provided in a hospital) should be entered as an outpatient request.

• Use Revenue Code 0023 instead of individual CPT/HCPCS code.  All the codes on your Home Health claim will be associated to this authorized Revenue Code.
  
  
• Date Ranges:
  • Initial Requests – Use the date of the initial assessment (OASIS) as the start of services date and day thirty as the end date.
  • Extend Requests – Use the first date of the next thirty-day episode of care.
    
    
• See the detailed step-by-step instructions available once you log into the Provider Portal.

• Use one frequently used treatment code (e.g., 97110).
  
  
• Do NOT use evaluation codes as they do not require authorization.
  
  
• Use the Episode of Care field at the bottom of the Authorization Details (second screen) to expedite the review of your request.
  
  
• See the detailed step-by-step instructions available once you log into the provider portal.

• When you enter a code that does not require authorization you cannot move forward in TruCare ProAuth™ to submit a request.
  
  
• Please fax an authorization request form with supporting clinical documentation to 207-828-7865, ATTN DME Early Replacement.

• Because you will not know the level of evaluation and management service you will need to bill we accept the range of office visit codes for new and established patient visits.
  
  
• Enter two lines on your request. Use code 99202 on the first line.
  
  
• Use the Add option to create a second line to your request and use 99215 on that line.
  
  
• Any codes in this range will apply to your authorization.

The instructions for requesting an organizational determination are included in the message you will see at the bottom of the Prescreen for codes that do not require prior authorization:

No auth required unless inpatient. NCD or LCD criteria applies. If you are aware that this service may not be covered by Medicare and are requesting an Organizational Determination by the health plan, please fax an authorization request form with supporting clinical documentation to 207 828 7865, ATTN Org Determination.

• You can enter retrospective authorization requests up to 120 days after the date of service.
  
  
• Requests that are older than 120 days from the date of service must be faxed.
  
  
• See the next FAQ for retrospective Generations Advantage authorization specific requirements.

• You can enter a retro request up to 120 days after the date of service in TruCare ProAuth™. (You must use the fax forms if your request is over 120 days since the date of service).
  
  
• In the Add Notes area of your request you can provide retro request information.
  
  
• We will review Generations Advantage retrospective authorization requests only under the following circumstances - Please read the complete definitions of these exception criteria before submitting a retrospective authorization request:
  
  
  • Urgent/Emergent: Requests for medical treatment required in order to prevent death or serious impairment of health, or medical treatment needed for an illness or injury that is not immediately life-threatening but requires professional medical attention to prevent a serious risk to the member’s health.
    
    
  • Unable to Know: When the provider did not have, and was unable to obtain, the patient’s insurance information pre-service (i.e., unresponsive patient delivered to an emergency room).
    
    
  • Not Enough Time: When the patient requires immediate or very near-term medical services (typically related to a service already being performed). For example, during a procedure, the provider identifies an acute need for hospital admission or, the procedure that evolves into a different/additional procedure which is performed immediately or scheduled for the same day
    
    
• Participating providers seeking retrospective authorization for a Generations Advantage member must file a claim for that service, wait for claim denial, and enter the retro information in the notes field of your request. If the situation meets one of the above criteria, with documentation that supports the “Urgent/Emergent,” “Unable to Know” or “Not Enough Time” exception. We will first assess the criteria for coverage and then for medical necessity.
  
  
• Non-participating providers seeking retrospective authorization for a Generations Advantage member must file a claim for that service, wait for claim denial and then initiate the claim appeal process on behalf of the member. We cannot begin the appeal process without a signed Waiver of Liability Form (PDF) and Medicare Appointment of Representative Form (PDF). You must attach these documents to your request.

To ensure immediate approval of referrals to participating specialists --- Be sure to enter the specialty type to which you are referring in the Provider Specialty field at the bottom of the second ProAuth screen.

Referrals to non-participating specialists will be reviewed for the need for the member to be seen out-of-network.

For more information see:

ProAuth™ Referrals Instructions (PDF)
USFHP Referrals Information Page

• TruCare ProAuth™ offers real-time authorization submission, status tracking and auto authorization responses.

• Interactive guidance helps you provide the information we need to process your request. This will decrease decision turnaround times and phone calls for more information.

• The data entered into TruCare ProAuth™ flows immediately into our authorization system so that we are able to review your request faster.

• Rather than calling to check on the status of your request you can check it any time. The status updates the moment a decision is made on your request.

 

This FAQ information is available to anyone.  Detailed training videos and instructional handouts are accessible once you have logged into the Provider Portal.

• All providers/staff who currently have access to Martin’s Point Provider Portal will be able to enter an authorization, through TruCare ProAuth™, for Generations Advantage and/or US Family Health Plan members.
  
  
• If your organization does not currently have a local administrator for the Martin’s Point Provider Portal but would like to have access to TruCare ProAuth™, please follow this link to register for access: https://martinspoint.org/account/register

Once you are logged in, you can visit our Change Password page.

For other user functions, please see our provider portal user guide found under System Documents at the Forms and Documents page.

If you are having trouble logging in, please visit the Forgot username or Forgot password page.

For other user functions, please see our provider portal user guide found under System Documents at the Forms and Documents page.

No, for security purposes every user will have their own username and password.

TruCare ProAuth™ works best when used in Google Chrome.

• For Martin's Point Members the instructions will state enter the 11-character member ID or the first 9 characters of the member ID and the member’s date of birth.
  
  
• To search by member ID:
  • Select Member Search on the navigation pane. The Member Search page opens.
  • Select Search by ID.
  • Enter the member's ID in the Member ID field, using the instructions specified on the screen.
    
    
• The Search button will not be active if you have not entered enough or too much information.

Yes, you will be able to see any information you have submitted by you/your provider.

• Go to the top right hand of your screen and look at your provider filter.
  
  
• If the circle is gray your provider filter is off.
  
  
• Click into the provider filter and select all the providers you want to be able to see.
  
  
• If the circle is green you have turned on your provider filter and will be able to see any authorization created under those providers.

No - At this time you cannot save and come back to complete the rest of the fields. You must enter all the information at the time of submission.

• Filenames can contain alphanumeric characters, dashes, and underscores
  
  
• You must use the ADD button to load the documents you will be submitting
  
  
• If you have difficulties uploading a document check with your own IT department to see if you have permission limitations or firewalls that might be the cause.

• As soon as you submit the authorization the system will send you to a page that will outline all the information you entered into the auth and at the top of the page will be your authorization number.
  
  
• You will also be able to see the authorization number when you are on your dashboard.
  
  
• You will also be able to see the status (pending, approved, or denied) of the authorization and monitor for status changes.

• Return to the Dashboard once you have submitted your request.
  
  
• Locate and click to highlight the authorization on the dashboard.
  
  
• Click on the View Details button. (If you have more than one code on the authorization click each line to expand to show the line details before you click the View Details button).
  
  
• Click to print. If printing select the printer. If you want a file created use the Print to PDF option.

• On the first screen (Prescreen) enter all required fields and click Next to see authorization requirement for that code.
  
  
• On the same screen (Prescreen) use the CLEAR button to remove the first code and enter the next code you need to check. Click Next to see authorization requirements for that code.
  
  
• Repeat this process to check all codes.
  
  
• Create your request using the ADD option for each code that requires prior authorization.
  
  
• A record of codes not requiring authorization will be logged which Martin’s Point staff will be able to view within the authorization tool.

• You can only enter one diagnosis code on the Prescreen (first screen) page.
  
  
• At the bottom of the Authorization Details screen (second screen) you will see a field called Secondary diagnosis. You can enter a second diagnosis related to your request in this field and use the + button to add more diagnoses.

• The TruCare ProAuth™ vendor has not removed these yet to allow for long term look back of authorizations prior to the conversion of ICD-10.
  
  
• If you accidentally use an ICD-9 diagnosis when creating your request you will experience difficulties submitting your request.

• For Outpatient services and procedures, you will use the ADD option to add a line for each code to your request.
  
  
• Be sure to use the same Service Type on each line. (See the next FAQ about Service Types)
  
  
• For inpatient surgeries/procedures the ADD option is not available. See the FAQ on Inpatient Surgical/Elective stays for instructions on how to enter your request.

• We can only have one service type per authorization.
  
  
• Use the primary service type on ALL lines of your request.
  
  
• Example: Home infusion with antibiotic should have Home Infusion as the Service Type on all lines of the request even the line with the drug code. Do not use Pharmaceutical as the service type on the line with the drug code.
  
  
• Example: Do not put physical therapy and occupational therapy service types on the same request. Each of those requires its own separate authorization.

Due to system limitations we ask that you call us at 888-339-7982 if you only need to change the dates on your existing authorization. We can quickly update your request while you are on the phone.

• Use the Extend option when you need to add more units to the same codes on the lines in your existing authorization.
  
  
• Use the Add option when you need to add more code to the request you are entering or new codes to an existing authorization.

• Services that should not be entered into TruCare ProAuth™ will display a message telling you what next steps you should follow.
• For mental health/substance abuse services for Generations Advantage Plan members call BHCP at 1-800-708-4532.
• For mental health/substance abuse services for US Family Health Plan members call BHCP at 1-888-812-7335.
• For Generations Advantage members ONLY – Optum™ will manage authorizations for the following:
  
  • Radiation Oncology
  • Medical Oncology
  • Specialty Part B drugs (Non-Oncology)
  • Call Optum at 866-572-941 or use Optum’s self service portal web portal

You must enable Pop Ups in order to log into TruCare ProAuth™.

• You CANNOT search for a provider by using a Tax ID number.
  
  
• You will see a number showing under Tax ID but it is not a valid Tax ID number.
  
  
• We are using the Tax ID field as a way to associate provider groups and manage provider filter lists.
  
  
• Best practice is to use NPI numbers to search for providers.

• The Servicing Provider field should be used to enter the Facility where the service will take place.
  
  
• This is important to verify whether or not the service will take place IN or OUT of network.
  
  
• Best practice is to enter the primary specialist/surgeon performing the procedure as the Requesting Provider, not the PCP or other referring provider.

Please see our provider portal user guide here.