Insurance Denial CO 38: Services Not Authorized by Providers

Insurance Denial CO 38: Services Not Authorized by Providers

Insurance Denial CO 38: Services Not Authorized by Providers

There are a number of reasons that insurance providers require prior authorization, including age, medical necessity, the availability of a generic alternative, or checking for drug interactions. A failed authorization can result in a requested service being denied or in an insurance company requiring the patient to go through a separate process known as “step therapy” or “fail first.” Step therapy dictates that a patient must first see unsuccessful results from a medication or service preferred by the insurance provider, typically considered either more cost effective or safer, before the insurance company will cover a different service.

Authorization in Medical Billing

Authorization in medical billing refers to the process wherein the payer authorizes to cover the prescribed services before the services are rendered. This is also termed as pre-authorization or prior authorization services. As the name recommend, the approval has to be obtained from the insurance payer for the proposed treatment or services.

There are certain method that mandate pre-authorization from the insurance provider. During the insurance eligibility verification process, we must ensure to verify on what services require prior authorization. The approval is based on the insurance scheme of the patient. Basis the benefit terms, required medical methods, insurance companies pre-authorize the request. A pre-authorization number is given by the insurance provider which has to be quoted in the final claim form which will be submitted post the treatment is completed.

Do I need permission or authorization from my insurance company before I get medical care?

If you are having a health emergency, you do not need to get permission to access emergency care. Health plans do not require permission or authorization for a sick or wellness visit with a primary care provider.

Prior authorization from your insurance company is different from receiving a referral from a primary care doctor. Some services require prior authorization in addition to a referral. Prior authorization gives the clinical staff at an insurance company the chance to review treatment protocol, available health care providers, and contribute to the course of treatment.  Sometimes prior authorization serves to determine that a health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary, and other times it may begin the coordination between a nurse case manager and the health care providers you will receive treatment from. Prior authorization does not guarantee your insurance company will cover the entire cost of authorized services.

Examples of the more common health care services that may require prior authorization include:

  • Planned admission to a hospital or skilled nursing facilities
  • Surgeries
  • Advanced imaging, such as MRIs and CT scans
  • Transplant and donor services
  • Non-emergency air ambulance transport
  • Medical equipment
  • Specialty drug treatments

Insurance Verification Services

  • Payable benefits
  • Co-pays
  • Co-insurances
  • Deductibles
  • Patient policy status
  • Effective date
  • Type of plan and coverage details
  • Plan exclusions
  • Claims mailing address
  • Referrals & pre-authorizations
  • Health insurance caps
  • DME reimbursement

How to Get Preauthorization from Insurance Companies?

You can submit your pre-authorization requests via telephone, online or by fax.

The procedure of obtaining pre-authorization for an eligibility verification company or doctors office starts with the insurance verification process. 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. Unauthorized claims will bring huge revenue loss. You can rely upon insurance authorization services to address any issue related to pre-authorization.



Learn More…

Complete List of Place Of Service Codes (POS) for Professional Claims

DENIAL CODE CO-197: How to Avoid Pre-Authorization Denial?