Authorization denial - How to resolve

When billing for services that require prior authorization, please ensure that you are placing the appropriate authorizations on your claim submissions. Claims that have services which require PA and no PA is present on the claim or in the Unisys system, will now deny for “requiring prior authorization” and will be the responsibility of the provider to correct and resubmit.

When billing for services that require prior authorization, the information on the prior authorization file must match the information submitted on the claim. If the information does not match, the claims will now be denied for “authorized services do not match billed services.” It will be the responsibility of the provider to correct and resubmit.

Below are some common authorization HIPAA reason codes with a definition and some helpful hints on correcting the claims.

Reason code - 62 M62 Missing/ incomplete/invalid treatment authorization code

Claim was submitted with a prior authorization number that is not valid
 

In the Unisys system. Consult your rejection reports from WVMI or APS, then resubmit the corrected information. The authorization might have been rejected due to member eligibility. 

Please verify that the member had eligibility on the ID number used on the PA request for the first date requested of the authorization time span.

Denial reason 15 N54/N351 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider.

This rejection is caused by any of the following claim information being inconsistent with the authorization:
 

• Member ID
• Provider ID
• Date(s) of Service
• Procedure code(s)
 

Verify that the correct authorization is being submitted for the information that is submitted on the claim.

Denial code 62 Payment denied/reduced for absence of, or exceeded, pre-certification/ auth

 

The authorization has either insufficient or zero units remaining for the service(s) Billed. At this point in time, claims that contain more units than are left on the PA are pending in the system. The claims are not being worked because the # of units that appear to be left on the PA is not always correct. The system will be fixed in the future to correct the # of used units on the PA when a claim is billed and processed. Until this system fix is completed providers can only be paid when the # of units billed is equal to or less than the # allowed on the PA. Once the fix has been implemented, pended claims will be reprocessed, the PA will be updated to reflect the correct # of units and pay the claim appropriately. Providers will be notified when the fix has been implemented and claims recycled. Unisys Provider Relations Unit can tell providers how many units appear to be left on the authorization at this time.

Posted in: Authorization / Referral