197: Precertification/Authorization/Notification/Pre-treatment absent

Denial Occurrence:

• This denial occurs when authorization is not obtained for a service or treatment that requires authorization.
• Authorization number can be found on Box# 23 on the CMS1500 form or Locator# 63 on the the UB04 form.
• Sometimes, the rep says the claim is denied as authorization is needed because the provider is out of network. In that case, do not consider it as Auth denial and follow the scenario of 242: Services not provided by network/primary care providers.
• Prior Authorization/Pre-Authorization: It is a process of obtaining authorization prior to performing the treatment.
• Retro Authorization: It is a process of obtaining authorization after performing the treatment.

On Call Scenario:

                                                        Claim denied as Authorization 
                                                               Absent or Missing
                                                                             ↓   
                                                          May I get the denial date?
                                                                             ↓
                                              Check in system if Auth# is Available
                                              ↙                                                         ↘
                                        Yes                                                             No
                                          ↓                                                                ↓
                 I have the Auth#, Can you please              Check place of service billed on
               reprocess the claim using this Auth#?          claim is 23 (Emergency) or not
                                          ↓                                   ↗       ↙                                     ↘
                               Rep Agrees?                       ↗        Yes                                       No
                              ↙              ↓                     ↗               ↓                                          ↓

                        Yes                No               ↗                   ↓                      Do you have Auth# on file? OR
                      ↙                 ↙        ↘        ↑          Could you please             Is there any hospital claim

   What is turn         Need to     Auth# is           reprocess the claim           billed on same DOS where

   around time         send an       invalid                 since it is an                    authorization# present?

 for processing?     corrected                             emergency service     (The above highlighted question

           ↓                    claim                                 & does not require           is only applicable for

  May I have the           ↓                                            Auth#?                 non-hospital billing claims)
claim# & call ref#?  What is                                           ↓                       ↗      ↙                          ↘
                                the time                                  Rep Agrees?          ↗      Yes                           No
                             limit to send                           ↙                    ↘    ↗           ↓                              ↓
                              a corrected                        Yes                      No               ↓                              ↓
                                  claim?                             ↓                              Could you please      Is it possible to
                                     ↓                       What is the TAT   ←  ←    use that Auth# and       obtain Retro

                          May I have the            for reprocessing?              send claim back for    Authorization#?

                       claim# & call ref#?                    ↓                                 reprocessing?        ↙            ↘

                                                                May I have the                                              Yes               No

                                                             claim# & call ref#?                                       ↙                       ↓

                                                                                                               What is the                What is the
                                                                                                        procedure to obtain      Fax# or mailing

                                                                                                              retro Auth#?            address to send

                                                                                                                        ↓                        an appeal?

                                                                                                             May I have the                    ↓

                                                                                                             claim# & call            How much is

                                                                                                                     ref#?                 the time limit?

                                                                                                                                                       ↓

                                                                                                                                            May I have the

                                                                                                                                             claim# & call

                                                                                                                                                    ref#?

Important Notes & Actions:

• Please take action as per your process update. Below actions can be different from your process update.
• If the Auth# is available in the system and the rep agrees to reprocess the claim then set the follow-up for the TAT provided by the rep.
• If the Auth# is available in the system and the rep denies to reprocess the claim and asks to send a corrected claim then update the Auth# correctly and submit the corrected claim by updating the correct billing code "7" along with the claim number.
• If the Auth# is not available in the system and the service is an emergency service and the rep agrees to reprocess the claim then set the follow-up for the TAT provided by the rep.
• If the Auth# is not available in the system and the service is not an emergency service and the rep finds Auth# on his/her system or on the hospital claim and agrees to reprocess the claim then set the follow-up for the TAT provided by the rep.
• If the Auth# is not available in the system and the service is not an emergency service and the rep does not find Auth# on his/her system or on the hospital claim but says that it is possible to obtain retro authorization then follow the procedure given by the rep.
• The procedure of obtaining retro authorization involves filling out the form and sending the requested documents. If the documents are available to you then you can fill out the form and attach the documents and send them to insurance.
• If the documents are not available then you can ask to client.
• If the Auth# is not available in the system and the service is not an emergency service and the rep does not find Auth# on his/her system or on the hospital claim and says that it is not possible to obtain retro authorization then the claim must be written off. But, sometimes clients want to send an appeal if nothing can be done. So work as per your client's instructions.
• Auth# can also be found on the Evicore website for the payers listed on the website. This website provides the Auth# approved for the specific CPT code under the specific time period.
• Few insurances advise contacting Evicore insurance to obtain Auth#. so if you have website access then you can directly check if Auth# is approved for the CPT or not else need to call Evicore insurance and find out the details.
• Click here to go to Quiz

Prepare Notes:

Source of Status:

* Call Website EOB System

Clearing House Comment (Please make the changes if required):

Insurance Name:

*

Clearing House Name:

Insurance Phone#:

*

Rep Name:

*

Website Name:

*

Denial Date:

*

Is Auth# available?:

* Yes No

Rep agreed to reprocess?:

* Yes No

Reason for not reprocessing the claim:

* Need to Send Corrected Claim Auth# Invalid

TAT for Reprocessing:

*

Corrected claim time frame:

*

Is claim billed with 23 or Emergency POS?:

* Yes No

Rep agreed to reprocess?:

* Yes No

TAT for Reprocessing:

*

Reason for not reprocessing the claim:

*

Did rep have auth# or find auth# on hospital claim?:

* Yes No

Did rep provide the procedure to obtain retro auth#?:

* Yes No

TAT for Reprocessing:

*

Procedure to obtain retro auth#:

*

Mode of appeal:

* Fax Mail Website

Fax Number:

*

Website Link:

*

Appeal Limit:

*

Mailing Address:

*

Additional Comment:

Claim Number:

*

Call Reference#

*

Action:

* Updated the Auth# and resubmitted the claim Need to allow time Need client assistance Need to submit an appeal Appeal sent Write off the claim



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