Wiki UHC Community Denials- Lack of Authorization for non participating Provider

[Reussite10]

Hi,

Our practice is a Cardiology that provides call coverage/emergency consultative and procedural health care/and emergent cardiovascular diagnostic reading for our local hospital.
On multiple occasions, we have to be DECLINED compensation of our care by United Healthcare Community on the basis of being an “out-of-network provider: lack of authorization". When our physicians take call for the hospital, they are obligated and responsible to see any patient in an urgent/ER when they are on call. During that hospital stay, consultation services/care/interpretative readings are provided BUT denied by UHC Community being “out-of-network providers and don't have the prior authorization.

Does anyone have a similar situation and how to deal with it? We appeal it but they upheld their the denial.
Thank you

 

[CLCameron]

Request a State Fair Hearing

I don't know what State you are in, but we run into the same issue here in Arizona. For us, pursuant to A.A.C. R9-22-202(E) prior authorization is not required for emergency services. We also look to 42C.F.R. § 438.114(a)/(c) and A.A.C. R9-22-201. We've had success with an ALJ overturning their denials (other MCO's as well). The carrier may argue that if the POS is not 23, then authorization is required; however there is nothing in applicable law (for AZ) that limits emergency medical services to only those services provided in a hospital emergency room.

It is often frustrating and surely time consuming, but I have found the end result is generally worth taking this type of denial to hearing.

Hope this helps.