Why Pre-authorization Is Critical To Medical Billing Success

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What do you do after you get back your verification of benefits?  First, you need to decide if you are going to move forward with medical insurance as a courtesy to the patient.

Next, you need to check and see if any of your codes need pre-authorization. If yes, then doing a preauthorization will be your next step.  In medical, unlike dental, if a code requires pre-authorization you must obtain it, or they will deny your case.  Very rarely do they grant retro authorization. At Imagn Billing, we always recommend applying for preauthorization as soon as possible. In order to file for the pre-authorization, you should ask the insurance representative during the verification of benefits call how that needs to be done:

  • Fax
  • Mail
  • Phone Call
  • Insurance Specific Form

With Imagn Billing, you can request a pre-authorization in minutes and our team will provide all the legwork of contacting the insurance company and getting the information that you need. 

  • Pre-Auth for Up To 12 Codes
  • Submission
  • Attachments
  • Aging and Follow Up Until Processed
  • Level 1 Appeal When Applicable

Be prepared to supply medical insurance with both the medical procedures and diagnosis codes. Chart notes will also be supplied either during the application process or shortly thereafter. 

Documentation & Organization 

Make sure you always have your list of documents in order before you call.  This list varies by procedure and can range from something as simple as chart notes to more complex things like letters of recommendation and outside provider referrals. A response for a preauthorization can sometimes come at the end of the phone call, or it could take up to 30 days. Typically, a response takes 10-15 business days, so make sure to plan the treatment accordingly.

There are several responses that may come for a preauth. They could say “yes, we agree to this covered service”, or “no, it’s not medically necessary” or “not a covered benefit/plan exclusion”.

It is important to stay organized when receiving pre-authorizations. Imagn Billing gives you the ability to filter your cases so when you are waiting for a response you can make sure no cases fall through the cracks. Below you can see how the pre-authorizations are filtered to show approved, submitted, and info sent to Imagn Billing.

Appealing Pre-Authorization Denials 

Appealing a denial based on the lack of medical necessity is possible but can be difficult. However, it’s even more difficult to appeal a plan exclusion. If you receive a medical necessity denial it either has to do with your coding or your supporting chart notes. You can appeal if a pre-auth is denied, but note that it is much harder to appeal a plan exclusion denial. If the services are approved then make note of the expiration date. All services covered under the authorization must be completed by the expiration date or you will have to apply for an extension or do a new authorization.

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