Question No prior authorization Appeal

tcosborne

Networker
Local Chapter Officer
Messages
32
Location
Montgomery, AL
Best answers
0
Can anyone offer any resources to help with claim denials due to no auth/referral on file? I know it varies from payer to payer. Also, is there anyone with experience involving Anthem Blue Cross regarding this issue?
 

OpenClaims

Expert
Messages
337
Location
Miami, FL
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0
Hello,

You can submit a PDR form, this is a Provider Dispute Resolution form. This form would be to request a retroactive authorization for the services already rendered. Once that is received, then you will rebill the service, make sure to include the PDR and retro auth.
 

csperoni

True Blue
Messages
1,975
Location
Selden
Best answers
3
This definitely does vary by carrier.
Basically, you were supposed to follow a specific step to authorize prior, and did not. Some insurances will make occasional exceptions, particularly if you can prove why this was unable to be done prior and the medical necessity. If it was just sort of "oops, we forgot.", some carriers will not pay regardless of how medically necessary or how many appeal letters you write.
The BCBS in my state is not Anthem BCBS, so I do not have any experience with them.
Good luck!
 
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