No Authorization

Purpose

To ensure the proper procedure is utilized when reviewing a denial received from a payer stating that no authorization was on file when one was required.

Policy

Post claim adjudication, the no authorization denial will be reviewed to ensure no false denial is received. The A/R team will review the account documents and claim to ensure the denial is accurate.

If there is an authorization or referral on file specifically referencing the date of service and/or type of services rendered, an appeal will be filed according to the payer guidelines.

If Clinicient cannot verify that appropriate authorization is in Insight, the clinic will be contacted to determine further action. If no response is received from the client by the timely filing limit for that payer, the claim will be written off with no further follow-up required.

Pre-Authorization Defined

Pre-authorization is the process of getting an agreement from the payer to cover specific services before the service is performed. Payers require prior-authorizations for numerous reasons including to protect patient safety and cost-containment. Pre-authorization does not guarantee payment of services rendered.

Pre-authorization requirements vary from provider to provider. Please check with your insurance providers for their specific policies.

Why

Per payer contracts and patient policies, some payers require a pre-authorization of services to determine medical necessity and to prevent over utilization of services. It is the clinic’s responsibility to understand each of their payer’s requirements.

Limited payers allow for a retroactive authorization after services are rendered. If the payer does allow this, there is a strict time requirement to submit the appropriate documentation.

 

Clinicient (the “Company”) is providing this information for general guidance. The application, impact and change of laws can vary widely. Accordingly, the information is provided with the understanding that it is not offered as legal or any other professional advice or services and as such should not be used as a substitute for consultation with professional and licensed advisers. While we have made every attempt to ensure that the information contained herein is accurate at the published time, the Company is not responsible for any errors or omissions, or for the results obtained from the use of this information. All information is provided "as is," with no guarantee of completeness, accuracy, timeliness or of the results obtained from the use of this information, and without warranty of any kind, express or implied, including, but not limited to warranties of performance and fitness for a particular purpose. In no event will the Company or its subsidiaries, agents or employees thereof be liable to you or anyone else for any decision made or action taken in reliance on the information.

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