| Claim denied for Authorization in Medical billing | ||
| 1 | May I know the claim received date | |
| 2 | May I know the claim denied date 06/16/2017 | |
| 3 | May I know why you required authorization for this service/cpt code the provider is ouun | |
| 4 | May I know whether you have any authorization# on your file | |
| 5 | Could you please check in the hospital claim whether you have any authorization | |
| 6 | May I know whether this service is covered in that authorization | |
| 7 | May I know the effective and termination date for that authorization | |
| If yes | If No | |
| Could you please send the claim back for reprocss with that authorization | Can we get the retro authorization for this service | |
| If yes | If No | |
| Get the retro auth and ask them to send the claim back for reprocess with that auth# else | whether we can submit claim with MR notes | |
| May I know the time limit to get the retro authorization | ||
| 8 | May I know the appeal limit and address | |
| 9 | May I know the fax# and whose attention it should be faxed | |
| 10 | May I know the claim# | |
| 11 | May I know the Call reference# |
For this denials we need to look into following 3 segments: Procedure code, Provider and Place of service to resolve the denials:
Procedure Code:
1) First check EOB/ERA to see which procedure code require authorization or reach out claims department and find out which procedure code require authorization.
2) Check in software application/claims department to see authorization available. If available and valid for the service, then update and send the claim back for reprocessing.
3) If authorization not available, then check with representative whether we can obtain retro authorization for that particular procedure code.
4) If we cannot obtain retro auth, then you have right to appeal the claim with necessary documents.
5) If appeal upheld, then escalate to the client for further action(Write off).
Provider:
1) First check provider is in-network or out-of-network provider with the insurance.
2) If its in-network provider, find out whether authorization required for the particular service. If authorization not required for in-network, then send the claim back for reprocessing.
3) If suppose authorization required, then follow the procedure code segment steps(2, 3, 4 and 5)
Place of Service:
1) First see the place of service code billed. Because if its an emergency, then authorization not required.
2) If the place of service is 23(Emergency), call the claims deparment and send the claims back for reprocessing.
3) If the place of service is some other and require authorization, then follow the procedure code segment steps(2, 3, 4 and 5)
