claim Authorization denial

Authorization or Referral Number Invalid or Missing

A valid authorization number must be included on the claim for all services requiring prior authorization. For all services requiring a referral, a valid referral number should be indicated on the CMS 1500 (HCFA 1500) form in Box #23 or on the UB-04 form in Box #63 or indicated in the appropriate section designated in the HIPAA Implementation Guide for the 837 transaction. A
copy of the referral must be submitted for all claims.

IMPORTANT – Missing or invalid authorization numbers and missing referrals for specialist, health care professionals or non-participating physician claims may result in processing delays or denials.

IMPORTANT – Only services specifically identified in the authorization will be reimbursed.

Claim Information Does Not Match Authorization

Authorized services provided to the member must be reflected on the claim as agreed to during the authorization process. Procedure codes, frequency, amount, and duration of services must exactly match the information in the authorization. If a medical need for a different service is identified, contact Utilization Management to change or update the authorization prior to the
provision of services.

IMPORTANT: Only services specifically authorized will be considered for reimbursement. hospitals, physicians and health care professionals may include a written description of services in addition to the appropriate HCPCS or CPT
codes as an aid in identifying authorized services. Although an authorization number is indicated on the claim, if the services billed do not match the authorization, the claim will be denied.

IMPORTANT – The service provider (i.e., the physician, health care professional or facility) on the claim must match the practitioner of facility authorized for the service. Inconsistencies may result in inaccurate payments or denials.

Posted in: Authorization / Referral