Wiki Payor Guidelines

West Branch, IA
Best answers
I am the office manager of a small GI group. I was recently told we need to verify every procedure to make sure prior authorization isnt needed. I am curious as to if there is a data base out there that you can enter your insurance ID/Group etc. in and pull up rather PAs are needed? or is there a Payer guideline tool out there for Colonoscopies? We have one for our pill cam, but it was created by the company. Just need an easier way than calling every single insurance policy that comes through our door to see if there is a PA needed. As we all know, PA's are not always the quickest process, and i can easily spend 45-60minutes on the phone obtaining one single PA, Let alone having to do all 20 that go through the door in one day.
Thanks in advance for your help. Looking forward to suggestions. Does anyone else deal with this? In the past we've had patients be responsible for knowing their benefits, but lately told that hospital has lost too much money due to PA's not being done.
There are some lists that you can use for payers. To be honest our office calls on a lot but we also put the information on Availity and it will either give you and authorization code automatically or it will pop up that none is required.

example of the payer list:

availity has payers from Aetna and BCBS:

For United Healthcare you can put in the CPT codes and it will also redirect you for an authorization or it will state non is required.

Unfortunately, we have not found a fool proof and more efficient way to date. Sorry.
Carrier Portals & Medical Guidelines

I've found utilizing the carrier portals directly are most useful. Create a provider login and pull the patient's benefits directly. Read the summary and see what procedures require pre-cert.

Alot of the carrier sites will also have search generators linked to their auth handler (evicore, etc) and it will let you know which CPT codes require pre-auth.

Hope this helps :)

Is anyone else having no luck getting authorization through evicore for Martin's Point Generation and Community Health Options for ultrasounds?