Question Denial claim

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Denver, CO
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I have a denial remit from BCBS. The reason code that was given was PR-243, which states "Services not authorized by network/primary care providers." What exactly does that mean, and what can I do to get any type of payment on this claim? I work for an eye surgery center, so I do not believe that we need to have authorization from the patient's PCP. I'm open to any suggestions.
 

sls314

Networker
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Toledo, OH
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I have a denial remit from BCBS. The reason code that was given was PR-243, which states "Services not authorized by network/primary care providers." What exactly does that mean, and what can I do to get any type of payment on this claim? I work for an eye surgery center, so I do not believe that we need to have authorization from the patient's PCP. I'm open to any suggestions.

Does the patient have a plan that requires a PCP referral?

If they have an HMO plan, they may have been required to have their PCP enter a referral. Did you verify benefits prior to the surgery?
 

thomas7331

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I have a denial remit from BCBS. The reason code that was given was PR-243, which states "Services not authorized by network/primary care providers." What exactly does that mean, and what can I do to get any type of payment on this claim? I work for an eye surgery center, so I do not believe that we need to have authorization from the patient's PCP. I'm open to any suggestions.
Yes, the payer is indicating that the services did need some kind of authorization or referral. If you disagree with that denial, you can question it or dispute it with the payer. But the 'PR' in the denial indicates that the payer has determined that the patient is responsible for the charges. You can bill the patient, and if the patient disagrees, they can take it up with their insurance company and fight that battle themselves and save yourself the time and trouble.
 

SharonCollachi

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Yes, the payer is indicating that the services did need some kind of authorization or referral. If you disagree with that denial, you can question it or dispute it with the payer. But the 'PR' in the denial indicates that the payer has determined that the patient is responsible for the charges. You can bill the patient, and if the patient disagrees, they can take it up with their insurance company and fight that battle themselves and save yourself the time and trouble.
Unless it's an HMO in a state that forbids billing the patient when the provider did not obtain an authorization... like here in California.
 
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