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Wednesday, April 20, 2011

MISSING UPDATE ON AUTHORIZATION INFORMATION

DESCRIPTION OF THE ISSUE
Humana HMO plans requested referral authorization for office and surgery services.  But most of the charges were not flagged properly with referral authorization.  Hence many claims were denied for request of authorization.

Non-participating carriers denied claims for authorization.

CONCEPT
Dr. Sondhi is a Gastroenterology specialist, for which Humana HMO plans with PCP other than our provider should contain referral authorization.

Our should be participating with the carriers for whom the claims were submitted.  If not then we require authorization to have the claims paid.

SOLUTION
During verification process, we started mentioning plans which require authorization.  Based on this information front office executives started retrieving authorization details. We initiated enrollment process for the provider, for the carriers which were non-par.

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