Wiki Documentation for Prior Authorization

[weshelman]

Have a patient who wants an insurance covered breast reduction. We have requested records from her doctors, but some of the doctors have only seen this patient as telehealth patients. I know that I need more information but can we use notes from a telehealth visit as documentation to request prior authorization?

 

[SharonCollachi]

Well you can use anything you want to request prior auth. However, without a physical exam, I would be surprised if it were approved.

 

[thomas7331]

Just to note, and a good piece of information to share with the patient as well: while obtaining a prior authorization may be a requirement, it does not ensure that a procedure will be covered. All payers that I know of will give you the disclaimer that an authorization is not a guarantee of payment. I have seen authorized procedures denied as not covered many times if they do not meet the coverage guidelines in the patient's plan. Your practice and the patient should review their plan's coverage rules for this service carefully and not just rely on an authorization.

 

[weshelman]

Well you can use anything you want to request prior auth. However, without a physical exam, I would be surprised if it were approved.

I thought that might be the case.

 

[weshelman]

Just to note, and a good piece of information to share with the patient as well: while obtaining a prior authorization may be a requirement, it does not ensure that a procedure will be covered. All payers that I know of will give you the disclaimer that an authorization is not a guarantee of payment. I have seen authorized procedures denied as not covered many times if they do not meet the coverage guidelines in the patient's plan. Your practice and the patient should review their plan's coverage rules for this service carefully and not just rely on an authorization.

I always share that information and have them sign a waiver.

 

[rachaelwilleford]

Coverage is determined by benefits, medical necessity, and plan guidelines. While a procedure will be denied for no authorization off the bat if one is not obtained if necessary, as Thomas noted above, make sure that plan guidelines are met and the plan provisions (benefits) cover this procedure.