Question

Ann is reviewing an encounter form for a CT scan of the knee. The patient is covered under an HMO plan, which requires preauthorization before the test is scheduled. Ann cannot find the preauthorization. She visits the online provider Web portal and finds out that no preauthorization was obtained. What can be done at this point? Will the claim be paid?

Answer 1

Preauthorization, prior authorization, precertification, notification are interchangeable for any procedure and situation. Providers are responsible for the certification number for reimbursement. Providers have to contact insurer in advance to get the preauthorization number for patient medical service. Insurance authorization plays an important role in the revenue cycle. It causes claim denial when patients not eligible for a procedure that billed by the providers. Health care providers are responsible for obtaining pre-authorization requests from the insurance company.
If no pre-authorization was obtained insurance company will not pay for the CT scan, the patient should be paid as a self-payer for the CT scan.