Most healthcare plans ask for pre-authorization for certain services rendered at a healthcare facility. The list of services may vary according to the plan and insurance company. The aim of the insurance pre-authorization process is to determine the eligibility of the member, benefit coverage, appropriateness of the service, medical necessity and location. If you fail to obtain pre-authorization for a particular service if it requires that, your claims for that service will be denied. 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.
Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.