Preauthorization: What If the Diagnosis Changes?

Q: Under the state's prompt pay rules, what if the patient's diagnosis changes between authorization and treatment? For example, you obtain preauthorization for an admitting diagnosis of a myocardial infraction, but after tests are done the diagnosis is changed to gastritis. Can the carrier deny payment for services performed to treat the final diagnosis? Can it refuse to pay for some of the inpatient days it initially authorized?

A: Preauthorization is a determination of whether proposed services are medically necessary; carriers issue preauthorizations based on the patient's diagnosis. If that diagnosis changes, you should contact the carrier or its utilization review agent and request a new authorization for the correct diagnosis. You should not expect a carrier to pay for all services or all hospital days that it initially authorized to treat a condition that ultimately was determined not to exist.

Content reviewed: 3/23/2007

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