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Precert/auth requirements for 2012 in 2011

  1. #1
    Default Precert/auth requirements for 2012 in 2011
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    Hi all,
    Any pointers on what to do when: a patient's insurance coverage terms on 12/31/11, the appointment/surgery is on 1/3/12, and the new insurance won't precert the procedure (or consider doing so) until the coverage becomes effective on 1/1/12. We're off 1/1 & 1/2/12, so now we have to cross our fingers and hope for the best when we come back on 1/3/12? Please advise/assist if possible

  2. Default
    I would file a complaint with your provider service rep. There should be no reason why they cant do they auth. They are supposed to auth based on medical necessity, and I would point this out to them, usually all insurances have a disclaimer stating that auths are based on medical necessity and not a guarantee of payment. I would also have the patient complain to their human resources department if this is a commercial plan through the employer. But I would say if you cant get the auth then the surgery may have to be rescheduled and I would tell the patient exactly why the insurance is being rescheduled so they can complain to their insurance company.

  3. #3
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    Quote Originally Posted by kdrebaker View Post
    Hi all,
    Any pointers on what to do when: a patient's insurance coverage terms on 12/31/11, the appointment/surgery is on 1/3/12, and the new insurance won't precert the procedure (or consider doing so) until the coverage becomes effective on 1/1/12. We're off 1/1 & 1/2/12, so now we have to cross our fingers and hope for the best when we come back on 1/3/12? Please advise/assist if possible
    Unfortunately, for many insurance carriers their computer systems will not recognize a patient in the system until the eligibilty date. They cannot provide auth for someone who is not yet in the system. If there is any question whether the auth for surgery will be allowed, I would counsel the patient that I will do the best I can, but they will be at risk of paying for the services in full if auth cannot be obtained. Often times in these situations, if it is not emergent, it is best to reschedule the surgery to a later date so that the auth can be obtained.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

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