Wiki Appealing No Authorization / No Precertification


Birmingham, AL
Best answers
Any advice would be appreciated:

I am appealing a surgery where no precertification was obtained so they are denying the surgery. What sort of information should I include in the appeal letter to convince the insurance company to pay? Does anyone have a tactic that they've found to work?

You did not state if this surgery was performed inpatient or outpatient. Some outpatient surgeries do not require precert. That should have been verified with the carrier prior to the surgical procedure. If there is documentation that procedure was verified and you were told "no precert required",(but now you are told it was required) you may be able to appeal. BUT insurance companies now have disclaimers that basically state they are not responsible for any misleading information given out so it is best to get it in writing if you can beforehand or reverified more than once. If the surgery was performed inpatient and your surgeon was not the admitting doctor, then the hospital should have a precert number for the hospital stay and that can be used as the "auth" number. If this was an emergency procedure then it should be appealed as such--no prior auth needed.

If none of the above apply because the ball was dropped somewhere down the line, then more than likely there is no appeal to a "higher court". The physician eats this one. It happens. Sorry not to be of help.

The surgery was outpatient. With United Healthcare, we normally don't need a precert for outpatient procedures, so the surgery scheduler didn't obtain one (or was told they didn't need one).

Sorry for not being more clear.
What if your doctor is contracted with a hosp. and they are required to get the precert/or auth and fail to do so. What should be done then?