Which of the following steps is needed to obtain precertification group of answer choices

Written by Kaitlyn Houseman | November 16, 2015

In the medical billing world, preauthorization, prior authorization, precertification, and notification are terms that may be used interchangeably to mean that for certain situations and procedures, providers have to contact insurers in advance and obtain a certification number in order to be reimbursed properly (or at all) for services. Insurance verification and insurance authorization services play a vital role in revenue cycle management. In fact, most claim denials happen when a patient is ineligible for services billed by the provider.

Depending on what the patient's coverage documents and the provider's contract with the insurer say, neglecting to obtain preauthorization can result in reduced reimbursements or lower benefits for the patient. Services that don't require preauthorization can be subject to review in some cases. Knowing which insurers require which preauthorizations can be complex, but your medical billing software and/or precertification tools provided by insurers can help medical billing specialists navigate the preauthorization maze.

Common Procedures That Require Preauthorization

Many insurers require patients to obtain referrals from a primary care physician before seeing a specialist. Hospital admissions that don't come through the emergency department often require preauthorization by insurers. Additionally, imaging studies like MRIs and CT scans often require preauthorization or something called "prenotification," which is more involved than a referral, but less onerous than a preauthorization. These processes result in an authorization number that providers must use on claims submitted for payment.

Providers have different policies about what they do when a patient doesn't have a referral, preauthorization, or prenotification. Some providers postpone treatment until proper authorizations are obtained, while others may go ahead with a procedure and try to retroactively get authorization. 

Correct CPT Codes: The Key to a Smooth Preauthorization Process

The best way to smooth the preauthorization process is for medical billing personnel to be prepared with the correct CPT code for the anticipated services. Of course, it's not always possible to determine the exact CPT code before a service has been provided. Communication with the physician is essential so you can learn what procedures he or she anticipates performing. It's best to learn all possibilities rather than risking that a procedure will be performed without preauathorization. In other words, it's better to authorize treatment that ultimately isn't given than to perform a procedure without preauthorization and risk not being reimbursed.In an emergency situation, patient coverage may not be known before the physician encounter. In these situations, providers are required to contact the insurer as soon as possible after the fact to obtain any necessary authorizations.

What Can Happen if You Don't Get Necessary Preauthorization?

When services are provided without expected preauthorization, what happens next depends on the insurer and the specific policy under which the patient is covered. Some insurance plans state that if a patient seeks services requiring preauthorization, but doesn't obtain preauthorization, the patient is liable for covering the payment. If a provider neglects to obtain preauthorization and payment is denied by the insurer, it may come down to absorbing the cost of the treatment or trying to collect it directly from the patient, neither of which are good options.

Can You Get Retroactive Authorizations?

With some insurers, you can get authorization retroactively, but with others, retroactive authorizations aren't given, even if failure to get it in the first place was a mistake. Still other insurers may overturn a denial based on lack of preauthorization if appealed, but generally they're not under an obligation to make the reimbursement if the process for preauthorization was not followed. If an insurer assigns full responsibility for payment to the patient for a procedure that wasn't preauthorized, you're put in the position of deciding whether to pursue collection from the patient.

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Prior authorization is necessary on many health plans for a variety of procedures.

 rubberball / Getty Images

If you’re facing a prior-authorization requirement, also known as a pre-authorization requirement, you must get your health plan’s permission before you receive the healthcare service or drug that requires it. If you don’t get permission from your health plan, your health insurance won’t pay for the service. You’ll be stuck paying the bill yourself.

Assuming you're using a medical provider who participates in your health plan's network, the medical provider's office will make the prior authorization request and work with your insurer to get approval, including handling a possible need to appeal a denial.

But it's also in your best interest to understand how this process works and advocate for your own care if necessary. Here are some tips to help get that prior authorization request approved.

While it’s your health insurance company that requires pre-authorization, it’s not necessarily your health insurance company that makes the decision about whether your prior authorization request is approved or denied. Although a few health plans still do prior authorizations in-house, many contract these tasks out to benefit management companies.

Your health plan may contract with a radiologic imaging benefits management company to process its prior authorization requests for things like magnetic resonance imaging (MRI) and computed tomography (CT) scans.

They may contract with a behavioral health benefits management company to process prior authorization requests for mental and behavioral health benefits. Your plan may contract with a pharmacy benefits management company to process prior authorization requests for certain prescription drugs or specialty drugs.

If you need to speak with a human in an effort to get your prior authorization request approved, the human most likely to help you is the clinical reviewer at the benefits management company. That person makes the decision to approve your prior authorization request, not someone at your health insurance company.

If you’re not sure which benefits management company is handling your prior authorization request, your health plan will point you in the right direction But, don’t count on your health plan personnel to be able to make the decision about approving or denying your request. Save your breath until you speak to the person who actually makes the decision.

In some cases, you can see the clinical guidelines the reviewers base their decisions on. This is kind of like seeing the answers to a quiz before taking the quiz, only it's not cheating.

Don’t know whether or not the guidelines you’re interested in are online? Ask your health plan or the benefits management company you’re dealing with for pre-authorization. If its guidelines are online, it’s usually happy to share them.

The more you and your healthcare provider know about the guidelines used to approve or deny a prior-authorization request, the more likely it is you’ll submit a request that's easy for the reviewer to approve.

You're much more likely to get a speedy approval if you give the reviewer exactly the information they need to make sure you meet the guidelines for the service you're requesting.

When your healthcare provider submits a request for prior authorization or appeals a rejected prior authorization, they should:

• Include clinical information that shows the reviewer you’ve met the guidelines for the test, service, or drug you’re requesting. Don't assume the reviewer knows anything about your health other than what you and your doctor are submitting.
• If you haven't met the guidelines, submit information explaining why not.

Let's say the guidelines say you're supposed to try and fail drug A before being approved for drug B. You didn't try drug A because you're actively trying to get pregnant and drug A isn't safe for a developing fetus. Make sure that's clearly explained in your prior authorization request. 

When you submit a prior authorization request, make sure the information you submit is totally accurate and is thorough. Prior authorization requests can be denied or delayed because of seemingly mundane mistakes.

A simple mistake could be having the request submitted for a patient named John Appleseed when the health plan member’s health insurance card lists the member’s name as Jonathan Q. Appleseed, Jr.

A computer may be the first “person” processing your request. If the computer is unable to find a health plan member matching the information you submit, you could be sunk before you’ve even started.

Likewise, it may be a computer that compares the ICD-10 diagnosis codes with the procedure CPT codes your healthcare provider submits in the prior authorization request, looking for pairs that it can approve automatically using a software algorithm.

If those codes are inaccurate, a request that might have been quickly approved by the computer will instead be sent to a long queue for a human reviewer to analyze. You’ll wait another few days before you can get your mental health services, your prescription drug, or your MRI scan.

If you’re having trouble getting prior authorization or have had a prior authorization request denied, ask to see exactly what information was submitted with the request.

Sometimes, when the clerical staff at a healthcare provider's office submits a prior authorization request, the healthcare provider hasn’t yet finished his or her clinical notes about your visit.

If the office staff submits copies of your last couple of office visit notes along with the prior authorization request, the notes submitted may not have all of the pertinent details about the medical problem you’re addressing in the prior authorization request.

With clinical information that doesn’t match your request, you’re unlikely to have your prior authorization request approved.

If your request for prior authorization has been denied, you have the right to know why. You can ask your healthcare provider's office, but you might get more detailed information by asking the medical management company that denied the request in the first place.

If you don’t understand the jargon they’re using, say so and ask them to explain, in plain English, why the request wasn’t approved. Frequently, the reason for the denial is something you can fix.

For example, perhaps what you’re requesting can only be approved after you’ve tried and failed a less expensive therapy first. Try it; if it doesn’t work, submit a new request documenting that you tried XYZ therapy and it didn’t help your condition.

Or if there's a reason you can't do that (perhaps the treatment you're supposed to try first is contraindicated for you due to some other condition or circumstance), you and your healthcare provider can provide documentation explaining why you cannot safely comply with the insurer's protocol.

While you have the right to appeal a prior authorization request denial, it may be easier just to submit a whole new request for the same exact thing. This is especially true if you’re able to “fix” the problem that caused the denial of your first request.

If you and your doctor feel that an appeal is the best course of action, know that the Affordable Care Act ensures your right to an internal and external appeals process (assuming you don't have a grandfathered health plan).

It's also important to make sure that your insurer is complying with the applicable federal and state regulations regarding prior authorization.

For example, an insurer cannot require prior authorization to determine medical necessity for mental health or substance abuse treatments if they don't have a similar protocol for medical/surgical treatments.

Most plans cannot require prior authorization before a member sees an OB-GYN or before emergency services are received. And many states impose their own requirements for state-regulated (ie, non-self-insured) health plans in terms of the length of time they have to complete prior authorization reviews and respond to appeals.

Your healthcare provider's office is likely well-versed in the applicable rules, but the more you understand about how they work, the better you can advocate for your own healthcare needs.