Wiki claim denial for lack of pre certification

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hrivera17

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My clinic failed to obtain pre cert prior to a CT scan being performed. I received a denial for no auth. Has anyone appealed this type of denial before and if so were you succesful in getting reimbursed? Not sure what my arguement would be. (The staff at the clinic overlooked the fact that the procedure required pre cert.) :confused:
 
Call the payer and ask if they will let you get a retroactive authorization/pre-cert for it. I don't bill radiology but sometimes a payer will let you get one after the fact, depending on the payer. It never hurts to try.
 
unfortunately this denial is almost impossible to appeal since its stated in the insurance policies that precert and pre auth is needed for certain cpt codes....we deal with this also when billing for cardiac nuclear imaging and if we failed to obtain an authorization and they dont allow retro, we have no choice but to writeoff claim since it was our error.

Sorry
Louise
 
No pre-cert

Factors to consider…Was this insurance carrier a secondary plan? Many of the rules of pre-cert are not required when another carrier is primary. Most carriers will follow the rules of the primary's insurance regarding that.

Another thing to consider is, did you call and verify eligibility prior to the visit? If so, did you talk to a live CS Rep and did they fail to tell you about what procedures needed pre-certification? Reason: I have won a previous appeal of no pre-cert before because the CS Rep did not transfer me to the pre-cert department after verifying benefits and they failed to tell me that one would be required after I had told them what CPT code I would be billing. If you verify online or through an automated phone tree they most often will tell you what services are covered and which need pre-certification.

In the future, you might want to just make it a rule that all CTs and MRIs are required to call the carrier prior to service to obtain an auth# or pre-notification#, could even use the call ref# for your records if an auth# is not required by the carriers CSRs words just to cover bases.
 
Hi -- I posted about this elsewhere... -- there are other ways to fight these kinds of denials... here is a free report by a friend of mine who is a lawyer...

I helped him create a report that shares 9 Tips that I think you could use... the report is free and short (13 pgs), but powerful -- use this link:"The Power To Get PAID".

Good Luck!
Ernie de los Santos
Faculty Chair
Appeal Academy
 
This type of denial basically has no appeal, if they will no issue a retro auth then you are done. There is no way to fight this and it is not an"illegal" denial. They followed the terms of the contract your clinic did not, it really is that simple. the newsletter cited, while interesting reading really has nothing to offer for this scenario.
 
We have successfully dealt with similar denials for a some payers by submitting records for medical review after the denial at the payer's instruction because they don't permit retro-authorizations. Instead of going through their precert unit, it goes through medical review. It's not always successful and is completely at the discretion of the payer but it doesn't hurt to ask. Call the Provider Relations rep if you can't get a straight answer from Customer Service.
 
Last edited:
trarut said:
We have successfully dealt with similar denials for a some payers by submitting records for medical review after the denial at the payer's instruction because they don't permit retro-authorizations. Instead of going through their precert unit, it goes through medical review. It's not always successful and is completely at the discretion of the payer but it doesn't hurt to ask. Call the Provider Relations rep if you can't get a straight answer from Customer Service.
Click to expand...

These are basically unappealable, however, this is a good suggestion. I've had luck doing this on very rare occasions. If the ordering provider can provide a letter stating the medical necessity it might also bolster your documentation for appeal.

Good luck.
 
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