TAR/SAR (Treatment/Service Authorization Request)

Objective
Determine the status of all the accounts sitting in the “pending TAR/SAR” work queue. The purpose of this is to make sure that all accounts are receiving prompt and appropriate attention.
  • Deferred: The Auth was sent back to the provider for more information or clarification in order to substantiate the request. The Auth will be denied if the provider does not submit the requested info/documentation within 30 days after the deferral (“no response received”).
  • Denied: The Auth has been received, reviewed and subsequently denied due to a number of reasons that include: services not medically necessary, lack of information, corrections, no response to a deferral and missing Pricing Indicator.
  • Rejected: A duplicate Auth Control Number was detected and therefore this latest request is being rejected. Provider must not reuse previous Auth numbers. This typically occurs when the provider responds to a Deferred Auth too late.
  • Approved: The Auth was approved as requested and the account is ready for billing.
  • Modified: The Auth was approved as modified (perhaps one or more requested days were denied) and the accounts is ready for billing.
  • Rejected: A duplicate Auth Control Number was detected and therefore this latest request is being rejected. Provider must not reuse previous Auth numbers. This typically occurs when the provider responds to a Deferred Auth too late.
  • In Review: The Auth has been received by the Field Office and pending review by one of their consultants.
  • Not Found: No Auth was detected in Medi-Cal’s PTN system. Either the Auth wasn't sent to the Field Office, was just recently sent or fell through the cracks somewhere along the line.
Summary
Novus will match records from the hospital’s ‘input’ file to the records in our database and produce an ‘output’ file that’s enriched with TAR/SAR data for each account (TAR/SAR Number, Approval Status, Date Received by Field Office, etc.). Included in another tab of the 'output' file is a dashboard that contains summary totals broken down by Status (Approved, Denied, In Review, Not Found, etc.).

Process
  • Hospital produces an ‘input’ file monthly, weekly or daily (client preference). The file should consist of all accounts exported from the “pending SAR/TAR” work queue to a spreadsheet. Minimum data requirements for the spreadsheet include:
    • Patient Name
    • Account Number
    • Admit & Disch Date
    • Medi-Cal/CIN ID#
    • Birth Date
    • Balance Amount
  • The ‘input’ is transferred to a dedicated SFTP folder (‘To Novus’)
  • Novus retrieves the input’ file during the nightly schedule and proceeds with a record-matching process that results in an ‘output’ file.
  • The ‘output’ file is transferred to a dedicated SFTP folder (‘To Hospital’) and ready to be picked up the following day