Authorization/Benefits Process

1. Call the insurance company, (the number is usually on the back of the insurance card) and ask for benefits.
– Obtain the in network benefits
– Obtain the out of network benefits as well if you are out of network with that plan
– Verify that the procedures performed are a covered benefit (typically 36478 and 36471)
– Ask to speak with the Authorization department and ask if this procedure(s) requires a pre-authorization, pre-certification, or a pre-determination
(do not believe the information from the benefits department that no authorization is required; this information is given incorrectly on a frequent basis)
– Verify the information given to you with more than one representative if they state no authorization is required. This may take multiple phone calls.
– Obtain the authorization. You should have the diagnosis code, the procedures requested, and all of the patient information at your disposal to complete this call.
– Requests for the diagnostic ultrasound and any clinical records along with a letter of medical necessity to be sent to the insurance for their review is not uncommon. It is highly recommended that a letter of medical necessity be written for all patient’s.

2. Document all conversations with the insurance company representative in either the chart or a financial chart including:
– Representative’s name
– Time and date of call(s)
– What information was given to you
– Verification of all codes that pertain the pending services
– Reference number for the call
– Authorization number

Things to watch out for:

UHC – do not believe that no authorization is required; ask for the authorization department as noted above, and verify all information. Services MUST have notification on file.

Cigna – The authorization department and claims department have conflicting information. It is very important to double check all information. It is also very important to make sure it is a covered benefit for that member’s plan.

BC/BS – Same as both of the above. Try to get all information in writing. Most Blues payers have a policy as of 01/01/08 that all EVLT procedures require an authorization.

3. Make sure your patient meets, and that you have documented, all conservative therapy requirements for that payer. It is good to keep a small reference file on what the conservative therapy requirements are for each major payer in your area. You can also ask the authorization department for this information when you check on an authorization number.

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