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CO 39 Services denied at the time authorization/pre-certification was requested.
AUTHORIZATION/REFERRAL PROBLEM
Action: Some carriers insist on obtaining prior authorization from them before the surgery. This may be 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 Surgeon and not the patient to obtain the authorization# from the carrier.
When you get a denial from the carrier for this reason, first check the system to see if any note entry has been made for the patient for the dos concerned and for the procedure in question. Always read the entire notes since the claim might have already sent for reprocessing. Same goes for other types of denials also. Pull out the original file and see if there is any auth# for the procedure and also pull out the original file received with the consult and check if we have received any auth# and if we have received, does the auth cover the procedure, that is check if diagnostic testing is marked and also check for the number of visits covered and the period it covers and communicate the same. If a valid auth# is found indicate the same and refile the claims, else mention the source file name and pg# of the original file along with the PCP’s name and phone #.So that we can get the Auth # for the same.
AUTHORIZATION/REFERRAL PROBLEM
Action: Some carriers insist on obtaining prior authorization from them before the surgery. This may be 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 Surgeon and not the patient to obtain the authorization# from the carrier.
When you get a denial from the carrier for this reason, first check the system to see if any note entry has been made for the patient for the dos concerned and for the procedure in question. Always read the entire notes since the claim might have already sent for reprocessing. Same goes for other types of denials also. Pull out the original file and see if there is any auth# for the procedure and also pull out the original file received with the consult and check if we have received any auth# and if we have received, does the auth cover the procedure, that is check if diagnostic testing is marked and also check for the number of visits covered and the period it covers and communicate the same. If a valid auth# is found indicate the same and refile the claims, else mention the source file name and pg# of the original file along with the PCP’s name and phone #.So that we can get the Auth # for the same.
Posted in: Authorization / Referral
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