ABA Pre-Determination Requirements – UMR – Advocate Insurance Billing

ABA Pre-Determination Requirements – UMR

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UMR normally does not require prior authorization for ABA therapy. But pre-determination is greatly encouraged, to reduce the records requests later from UMR. Here are the details so that we can assist your clinic in completing the Pre-Determination process with UMR for this patient.

Pre-Determination Requirements

Step 1 = After clinic performs initial assessment (no PA required), clinic provides Advocate (AIB) with the treatment plan for ongoing care, and any other clinicals they have (psych eval, etc.). Clinic uploads this information to AIB via Teamwork channel. This needs to be provided to AIB BEFORE the patient begins active ongoing care.

Step 2 = AIB calls UMR Behavioral Health Pre-Determination department to begin the pre-determination process, providing them with the timeframe of the 6 months of care, and the units needed etc. UMR assigns a Case # for this pre-determination.

Step 3 = AIB will fax in to UMR the needed clinicals for the pending Case #.

Step 4 = Within 10-15 calendar days, UMR will fax or mail to clinic the pre-determination results. When you receive pre-determination approval from UMR, please upload the approval letter to AIB in Teamwork.

Note
Ongoing care can begin before the pre-determination results are in. We just must begin the pre-determination process before ongoing care begins, as UMR will not backdate a pre-determination.

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