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Importance of Pre-Authorisation in Healthcare

Pre-Authorization : Most important part of Revenue Cycle Management process. When we talk about pre-authorization or certification in medical terms, we are referring to the process of reviewing the treatment being provided or to be provided by a healthcare provider to a health insurance subscriber.

Understand the pre-authorization process for healthcare providers
Before a healthcare provider can provide services, they need to obtain pre-authorization from the insurance company. This process involves submitting information about the proposed service and getting approval from the insurance company. If the service is approved, then the healthcare provider can go ahead and provide it. If not, then the provider may have to cancel or reschedule the appointment.

Learn what information is required to submit a request.
The information that is typically required to submit a request for pre-authorization from health insurance includes :

  • The patient's demographics, subscriber policy number
  • The physician's name, address, and phone number
  • Details about the requested treatment or procedure
  • Medical records supporting the treatment requested, like Radiology, Lab tests, etc.

Gather all of the necessary documents and information.

  • The name and description of the service or procedure being requested, Date of Service.
  • You can also include any other documentation that may be helpful in determining whether or not pre-authorization is needed.
  • Adding supporting documentation with the request for authorization can help in Utilization Reviewer determining the medical necessity for service being request.

Submit a request for pre-authorization online or by mail.
To submit a request for pre-authorization, you have many options depending on the insurance to insurance: some insurers offer online requests or to some we have to request by mail or fax. Online submission is the quickest and easiest way to get your request processed, while mailing in your request will take a little longer. Regardless of which method you choose, make sure to include all of the requested information so that we can process your authorization as quickly as possible.

Follow up on requests to ensure they are processed in a timely manner.
After sending the documentation required to for Pre-Authorization, there is certain timeline by which insurance company should respond to the provider however sometimes payers (Insurance companies) generally don’t adhere to their own guidelines and hence provider have to spend his precious time in finding out the status of his request, thus resulting in delay of the treatment needed.

Prior Authorization in Workers Compensation :
When it comes to the authorization process for workers' compensation payers in California, pre-authorization is the first thing that comes to mind. After SB863, it became mandatory for all medical providers who want to provide services to injured workers to seek authorization. The Department of Workers Compensation State of California requires all providers to submit a request for pre-authorization before providing any services. Because of this mandate from DWC, providers have to use a specific format when submitting RFA's, and they must include any supporting documentation as evidence.

Payers have 5 days to respond to the request for authorization, if any treatment that is being denied from the requested injured workers or its attorney can request independent medical review (IMR), the decision from IMR is final in this case. In general sense, medical providers who are treating injured workers are allowed to provide the medical treatment which is according to MTUS guidelines provided by DWC.

Requesting authorization and tracking can be a tedious process for providers and can consume a lot of staff time. Meraki RCM Solutions, LLC has experienced staff who are dealing with requests for authorization on a daily basis and can help your practice to do so, boosting the revenue for your practice in the process. This service is available on an à la carte basis or as part of our complete billing and collection service package.

If you are looking for a hassle-free way to get pre-authorization for your patients, give us a call. We are here to help!

Contact: Meraki RCM Solutions, LLC
Phone: +1(562)375-0472

Tag: Medical Billing / workers compensation/ Denied Claims

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