So a health plan has denied your preauthorization request for a patient’s treatment. What options do you have?
First determine the patient’s type of coverage.
Medicare Advantage plans have specific appeal guidelines, which you can find on the Centers for Medicare & Medicaid Services website. Be sure to check out the appeals flowchart.
Commercial health plans also post specific appeal guidelines on their websites, typically as part of their provider manual. Before providing a service, you should always check to see if the health plan has a notification and/or precertification requirement. Finding out in advance about the coverage and benefits available for a service is advantageous for both you and your patients. Some services may require notification only, while for others, health plans may require you to submit medical records for review before they determine if the services meet plan guidelines for medical necessity.
In 2013, as a result of hard work by TMA, the Texas Legislature passed bills to develop and require health plans to accept a standardized prior authorization form for both medical services and prescription drug benefits. Read details about the forms in this Texas Medicine article. Both forms are available for download on the Texas Department of Insurance (TDI) website, along with links to the Texas Administrative Code (TAC) rules that address the use of these forms.
The code also addresses preauthorization for HMOs and preferred provider benefit plans. They must adhere to specific time frames when responding to preauthorization requests from physicians and providers. Finally, the code specifies written procedures for appeal of adverse determinations when a request for preauthorization is denied. (All these rules are in 28 TAC, Chapter 19.)
In 1997, the Texas Legislature made Texas the first state to require a system of independent review of insurer decisions by reviewers who do not work for the insurance company or HMO. Use of the Independent Review Organization (IRO) process usually is permitted only after patients have completed the insurer's internal appeals process.
If you believe a health plan is not complying with any one of these requirements, you may file a complaint with TDI. Patients may also file complaints regarding their health plan and should be encouraged to do so. Step-by-step guidance through the insurance complaint process is on the TDI website.
When you have questions about billing or payer policies, contact TMA’s reimbursement specialists for help at paymentadvocacy[at]texmed[dot]org, or call the TMA Knowledge Center at (800) 880-7955. TMA members can use the TMA Hassle Factor Log to help resolve insurance-related problems. Visit www.texmed.org/GetPaid for more resources and information.
Published April 13, 2017
TMA Practice E-Tips main page