Prior Authorization

Before any request is built, we check whether the payer requires an authorization for that service, that site and that provider. Most denied requests were not denied on medical grounds. They were denied because the payer did not receive what its criteria asked for. Each plan publishes, in its medical policy, the documentation it wants to see for a given service: a diagnosis at a particular specificity, a history of conservative treatment and its outcome, imaging or laboratory results, a functional assessment. A request that goes in as a procedure code and a diagnosis code with nothing attached asks the payer to guess, and the payer does not guess. It pends the request for information, or denies it.

The second common cause is the wrong request. The CPT code on the request does not match the code that will be billed, the number of units is lower than the treatment plan needs, the site of service is different from the one where the service is performed, or the request names a facility when the payer wanted the rendering provider. Any of these produces an approval that does not cover the claim that follows.

Both causes are avoidable before submission: check the plan's policy for that service, gather the documentation it lists, and build the request from the same codes, units and provider that will appear on the CMS-1500.

The second common cause is the wrong request. The CPT code on the request does not match the code that will be billed, the number of units is lower than the treatment plan needs, the site of service is different from the one where the service is performed, or the request names a facility when the payer wanted the rendering provider. Any of these produces an approval that does not cover the claim that follows.

Both causes are avoidable before submission: check the plan's policy for that service, gather the documentation it lists, and build the request from the same codes, units and provider that will appear on the CMS-1500.

Where a service was delivered before a request could be made, as with an emergency admission or an unplanned procedure during a scheduled one, some plans accept a retrospective authorization request within a stated window after the date of service. Others do not, and a service delivered without authorization under those plans is not recoverable from the payer.

The practical consequence is that the retrospective rule for each of your payers is looked up and recorded before it is needed, so that when an urgent service happens the request goes in inside the window, and when the plan allows no retrospective request the practice knows that on the day rather than on the remittance.

This is where courses of care are lost. Physical therapy approved for twelve visits reaches the thirteenth. Infusions approved for six months continue into the seventh. A behavioral health authorization is renewed by the payer with a new reference number that never reaches the biller, so the claim goes out with the expired one and denies as an invalid authorization number.

Every approval is logged with its reference number, codes, units, start date and end date, against the patient and the treatment plan. Units are decremented as visits are billed. When remaining units or remaining days fall below an agreed threshold, a continuation request is prepared while the current authorization is still live, and the new reference is passed to billing before the first claim that needs it.

Peer-to-peer conversations are between clinicians. We schedule them, prepare the criteria and the points of disagreement, and record the outcome, but the provider holds the call.