News and Notes from The Johnson Center
Pre-Authorizations and Insurance: What You Need To Know
JCCHD | Thu, June 04, 2015 | [Autism Treatment]In our NAVIGATING INSURANCE webinar on May 21st, we discussed the Pre-Authorization process [sometimes called Pre-Certification]. Many insurance companies require pre-authorization to help determine whether a proposed treatment plan is necessary. We suggest you call your insurance company prior to any specialty or out-of-network clinical visit. This is especially important if you are starting an intervention that is specialized (such as a Feeding Clinic) or recurring (like speech therapy). If any services are performed prior to gaining pre-authorization it may result in you being financially responsible for all or part of the cost of the services.
Let’s say your physician and therapy team determine that a behaviorally-based Feeding Clinic is critical for your child’s development and progression. The Feeding Clinic is projected to last 5 days with 3 two-hour meals daily (6 hours of ABA x 5 days = 30 hours, plus parent training time). Even if your insurance is covering ABA services on an ongoing basis, it is prudent to get a pre-authorization for the specialized Feeding Clinic.
Pre-authorization forms must be completed and sent with statements of necessity from the prescribing clinician. Sometimes your clinician will submit the forms on your behalf. For the sake of expediency, you may need to gather information and documents from various clinicians to submit the pre-authorization request on your own. You will then wait for confirmation in writing that insurance will cover this service before you begin. Typically, insurance carriers must respond to a pre-authorization request within 30 business days. Be sure to use the Insurance Worksheets on all of your calls and keep copies of all the paperwork in your insurance binder. Mark the date on your calendar to call about the verdict!
Here’s the typical pre-authorization process for insurance companies:
• A member or provider will make the request for pre-authorization in writing and submit all necessary records to the insurance company. When a member goes to a non-network physician, it is the member’s responsibility to obtain pre-authorization.
• A Clinical Coverage Review Department then makes coverage decisions for pre-authorization, based on the submitted medical record information.
• Once a provider or member submits a request, the insurance company typically makes a decision within three business days. The decision could take up to 15 days if the provider or member does not initially submit all necessary information to make a determination. For urgent requests, the insurance company usually makes a decision within 24 hours.
• An appropriate reviewer, such as a board-certified physician or specialist, makes the final determination on all denials.
• A copy of the decision is faxed or mailed to the provider and mailed to the member.
• In the event that coverage for a requested procedure, drug, or service is denied, members have the right to appeal, as outlined in their plan documents.
File all your paperwork on the pre-authorization approval in your insurance binder, as your clinician may need approval codes or reference numbers from these documents during their billing process.
And remember, if needed, you can always appeal a pre-authorization denial!
