Denial Code CO 197: Precertification/authorization/notification absent.
Some of the insurance companies request to obtaining prior authorization from them before the service/surgery. This may be required for certain specific procedures or may even be for all procedures. So, these are carrier-specific and procedure-specific. Please note that it is the responsibility of the Physician/Surgeon and not the patient to obtain the authorization# from the insurance company.
With some insurers, you can get authorization retroactively, but with others, retroactive authorizations aren’t given, even if failure to get it in the first place was a mistake. Still other insurers may overturn a denial based on lack of preauthorization if appealed, but generally, they’re not under an obligation to make the reimbursement if the process for preauthorization was not followed.
MISSED TO TAKE PRE-AUTHORIZATION?
When services are provided without expected preauthorization, what happens next depends on the insurer and the specific policy under which the patient is covered. Some insurance plans state that if a patient seeks services requiring pre-authorization, but doesn’t obtain pre-authorization, the patient is liable for covering the payment. If a provider neglects to obtain pre-authorization and payment is denied by the insurer, it may come down to absorbing the cost of the treatment or trying to collect it directly from the patient, neither of which are good options.
The provider has to make a decision about whether to pursue collecting the payment from the patient. Some swallow the loss. Others send the unpaid bill to the patient, but doing so is bad business. Patients are both unaware of the process and not in any sort of position to guess what CPT code should be submitted to the insurance company.
WHAT IS PRE-AUTHORIZATION?
Before insurance companies will agree to pay for some medications, medical procedures, and medical equipment, they require advance notice from physicians. If authorization is not obtained prior to performing the service, the insurance company may not reimburse for the procedure. Depending on what the patient’s coverage documents and the provider’s contract with the insurer say, neglecting to obtain preauthorization can result in reduced reimbursements or lower benefits for the patient.
HOW TO TAKE PRE-AUTHORIZATION?
Once the patient is scheduled for a procedure or a healthcare service, you should initiate the verification process and enquire with the insurance company whether this particular procedure or service requires pre-authorization or not. If the company says it is required, initiate the pre-authorization request. Include the following information in the request such as:
- Patient’s name, address, phone number, insurance ID and insurance status
- Provider name, address, phone number, specialty, tax ID number and National Provider Identifier (NPI) number
- Describe the requested services including duration dates and total number of visits along with specific CPT/HCPCS codes
- Diagnosis along with appropriate ICD codes
- Reason for pre-authorization
- The facility where the procedure is performed (facility’s Tax ID number, NPI number, address, phone and fax number)
You should submit medical notes along with it. After submitting your request, the insurer may sometimes ask for additional details to give pre-authorization. In that case, you must submit other documentation including the details regarding previous treatment and clarification regarding the type of service provided. It takes five to thirty days to approve a request.
If it is a medically urgent request, you should include the information that meets the criteria for an urgent request in your pre-authorization letter. If your request is rejected, you can file an appeal after reviewing your pre-authorization process. However, you should obtain pre-approval as early as possible as you have to append the pre-authorization number along with your claims.
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