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.

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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.

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HMO

HMO is a term health maintainance organization which means group of doctors will participate in the group (HMO) to various service to patients.

HMO require an authorization in order to see a specialist in case the PCP itself is not a specialist ,if PCP is itself specialist in the treatment no authorization needed.

In emergency case also no need of authorization in HMO, the main moto of the HMO is to provide the cost effective and affordable service at right.

Also HMO will have the periodic check up to prevent disease ,because periodic check up will allow a patient to find out how he was affected and according to that seviourity the treatment will be provided and cured .

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Insurance denial - CO 39 Services denied at the time authorization/pre-certification was requested.

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.

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