Wiki Appealing No Precert/No prior authorization

[lizzardb]

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?

Thanks!

 

[genjer712]

I work for an insurance company and have for over 4 years. We see claims denied often where no pre-cert was obtained. When an appeal is needed, we often look for the main reason why an appeal was not done in the first place. Was it an emergency surgery vs elective? No insurance info given at the time of scheduling? Incorrect benefit information given when speaking with insurance company?...etc. Any details you can give as to why there was not a precert done will better your chance of a denial of benefits being overturned. Good luck!