Tuesday, June 1, 2010

Prior Authorization denial - How to resolve and appeal

When billing for services that require prior authorization, please ensure that you are placing the appropriate authorizations on your claim submissions. Claims that have services which require PA and no PA is present on the claim or in the Unisys system, will now deny for “requiring prior authorization” and will be the responsibility of the provider to correct and resubmit.

When billing for services that require prior authorisation, the information on the prior authorization file must match the information submitted on the claim. If the information does not match, the claims will now be denied for “authorized services do not match billed services.” It will be the responsibility of the provider to correct and resubmit.

Below are some common authorization HIPAA reason codes with a definition and some helpful hints on correcting the claims.

Denial reason 15 N54/N351 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider.

This rejection is caused by any of the following claim information being inconsistent with the authorization:
• Member ID
• Provider ID
• Date(s) of Service
• Procedure code(s)

Verify that the correct authorization is being submitted for the information that is submitted on the claim.

Denial code 62 Payment denied/reduced for absence of, or exceeded, pre-certification/ auth

The authorization has either insufficient or zero units remaining for the service(s) Billed. At this point in time, claims that contain more units than are left on the PA are pending in the system. The claims are not being worked because the # of units that appear to be left on the PA is not always correct. The system will be fixed in the future to correct the # of used units on the PA when a claim is billed and processed. Until this system fix is completed providers can only be paid when the # of units billed is equal to or less than the # allowed on the PA. Once the fix has been implemented, pended claims will be reprocessed, the PA will be updated to reflect the correct # of units and pay the claim appropriately. Providers will be notified when the fix has been implemented and claims recycled. Unisys Provider Relations Unit can tell providers how many units appear to be left on the authorization at this time.

How to avoidReferral/Prior Authorization Request Delays or rejection - Tricare guidelines

The following guidelines will help expedite your referral and authorization requests:

•     Submit an online request or, if that option is not available to you, use the TRICARE Patient Referral/Authorization Form for any TRICARE Prime beneficiary requiring a specialty care referral or a prior authorization for any TRICARE West Region beneficiary who requires prior authorization for services on the Prior Authorization List

     Submit complete online referral and authorization requests with physician documentation and all clinical indications, including laboratory/ radiology results related to the requested service. Attach relevant documentation to your online request. If you have an electronic medical management system, you may also copy/paste from that system into your online request. If you are unable to submit your requests online, submit a complete and legible TRICARE
Patient Referral/Authorization Form by fax.

•     If you submit referrals and authorizations online on a regular basis, please use a Request Type profile that includes your requested codes.

* TriWest has online user guides to help you select the correct Request Type profile. TriWest has more than 100 profiles and using them will eliminate any code range issues. If you cannot use a profile, TriWest limits code ranges (low and high) to 10 codes. If the code range is more than 10 codes, the user will get an error indicating that the “allowable” code range has been exceeded and will have to put in a code range less than 10 codes. The user will not be able to enter the request until there is an acceptable code range.

•     Be specific about the requested services and provide the most appropriate procedure and  diagnosis codes. Requests for DME also require complete information on applicable codes. A reasonable range is acceptable.
Include National Drug Codes (NDCs) for medication requests.

•     Make sure the correct ICD-10 and Current Procedural Terminology (CPT®) code(s) are included. Include clinical documentation for services on the Prior Authorization List.

Be sure to clearly reference your contact information, particularly the fax number to which TriWest should respond. Incomplete forms may slow the process.

•     When pictures are needed to support the requested service, the preferred method of submission is to use the online referral and authorization tool
and attach a digital photograph to the request.

Pictures sent via fax do not transmit clearly and may delay the process while
TriWest requests and awaits receipt of originals.

•     Generally, approvals are active for 180 days, unless otherwise indicated on the referral/ authorization approval letter. If the servicing provider is unable to provide the approved services prior to the expiration of the referral,
a new referral/authorization request must be submitted. If it has been 180 days or more since the initial approved request for the same diagnosis, the PCM should request the new referral/authorization. If the specialist has obtained a referral from the PCM within 180 days, the specialist may make the request
for services related to the same diagnosis.

If the servicing provider wishes to add additional procedural or treatment codes to the approved referral or authorization, then a new referral/
authorization request must be submitted covering the additional requested services.

•     Verify the beneficiary’s demographic information (sponsor’s Social Security number, address, date of birth, etc.) and include it on the request form.

•     When using the fax process, you only need to fax your referral or authorization request once, if you have confirmed that you faxed the referral
to the correct number and have a confirmation from your fax machine. Re-faxing creates duplicate requests and delays processing. You may check the status of your request online at any time if you are registered with
www.triwest.com/provider, regardless of whether the request was submitted online or by fax. You may also call 1-888-TRIWEST (1-888-874-9378) if you have not received a response within five days.

•     When using the fax process, send only one completed TRICARE Patient Referral/ Authorization Form per fax. Sending multiple requests under one fax cover sheet increases the processing time.

•     Approved referrals are faxed to provider offices between midnight and 3:00 a.m. daily. It is important to leave (secure) fax machines on after hours to ensure prompt receipt of authorizations from TriWest. You may also obtain the status of services for which you are the approved servicing provider 24 hours a day,
seven days a week online if you are registered with www.triwest.com/provider.

•     Remember to submit the CPT or Healthcare Common Procedure Coding System (HCPCS) codes for services requested. “Episodes of care” (EOC) have been developed for common types of health care service requests that have also
been identified as having potential for claims processing errors. Experience shows that additional services are commonly requested, subsequent to the initial request. In such cases, more services may be approved than requested; providers should only provide medically necessary services.

 Reason code - 62 M62 Missing/ incomplete/invalid treatment authorization code

Claim was submitted with a prior authorization number that is not valid
In the Unisys system. Consult your rejection reports from WVMI or APS, then resubmit the corrected information. The authorization might have been rejected due to member eligibility. 

Please verify that the member had eligibility on the ID number used on the PA request for the first date requested of the authorization time span.

Preauthorization Appeal Procedures

If you or your Physician disagree with the determination of the preauthorization prior to or while receiving services, you may appeal that decision by contacting BCBSTX's Administrative Office.

In some instances, the resolution of the appeal process will not be completed until your inpatient admission or service has occurred and/or your assigned length of stay/service has elapsed. If you disagree with a decision after claim processing has taken place or upon receipt of the notification letter from BCBSTX, you may appeal that decision by having your Physician call the contact person indicated in the notification letter or by submitting a written request to:

Claim Review Section

Blue Cross and Blue Shield of Texas
P. O. Box 660044
Dallas, Texas 75266-0044

Once you have requested this review, you may submit additional information and comments on your claim to BCBSTX as long as you do so within 30 days of the date you ask for a review. Also, during this 30-day period, you may review any documents relevant to your claim held by BCBSTX, if you request an appointment in writing.

Within 30 days of receiving your request to review, BCBSTX will send you its decision on the claim. In unusual situations, an additional 15 days may be needed for the review and you will be notified of this during the first 30-day period.

Notification or Prior-Authorization Denial Appeals


An appeal request for a claim whose reason for denial was failure to notify or pre-authorize services.


• A claim denial because no notification or authorization is on file.

• A claim denied for exceeding authorized limits. 

Appeal Requirements and Required Documentation

• All provider appeals must be submitted with a completed Request for Claim Review Form.

- Claims submitted without a Request for Claim Review Form will be treated as a first submission, which may result in a denial.

• Copy of the original supporting EOP

• One of the following:

- HPHConnect claim detail screen
- NEHEN Claim Status Response claim detail screen

Supporting Documentation

When submitting a written administrative or clinical appeal, it is necessary to include all supporting documentation specific to the denied claim. Appeal submissions must include the most appropriate supporting documentation.

Examples of documentation must include copies of one or more of the following:

• Surgical/operative notes

• Office visit notes

• Medical

• Pathology notes

• Medical record entries

• Medical Invoices (e.g. DME or pharmaceuticals)

Letter or explanation describing the issue (letters of explanation will not be considered without medical record documentation)

Medical Record Documentation and Physician Queries

Harvard Pilgrim will not accept retrospectively amended medical records or physician queries beyond 30 days from the service date.

Harvard Pilgrim considers medical record documentation and/or physician queries upon review as the official record to support services provided for the basis of coverage or reimbursement determination.

Clinical documentation or physician queries amended over 30 days from the service will not be accepted to defend reimbursement, increase reimbursement, or consideration of a previously denied claim. 

0155  Procedure Requires  Authorization

The procedure/revenue code billed requires a preauthorization and there is no PA number on the claim. You must get  preauthorization from the appropriate area depending on the service being provided. The preauthorization number received is required on the claim.

0485  Authorization by Medallion PCP Not Indicated

The members primary care provider must authorize services

0161  Authorization Not Valid for Dates of Service

The payment request's from and thru dates of service must fall within the PA's begin and end dates. CMS – 1500 and UB-04: Please verify the correct PA number was entered.

0157  Approved Authorization Not on File

The procedure billed requires authorization and the authorization is not on file. Verify that the authorization number on the claim is the correct authorization for the service billed.

0162  Number of procedures exceeds number authorized

The number of units or visits billed is greater than the number of units or visits authorized on the PA

0158  Enrollee Disagrees with Authorization

The authorization number used on the claim is not for the same enrollee as billed.

0160  Procedure Disagrees with Authorization

The procedure billed on the claim is not the same procedure that has been authorized.

0191   Provider Referral Required 

The procedure code entered on the CMS-1500 or the revenue code on the UB-04 requires a referral, Verify the correct provider number is entered correctly on the claim.

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